Provider Demographics
NPI:1407058142
Name:BUSTAMANTE, ALEJANDRO
Entity Type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ALEJANDRO
Other - Middle Name:
Other - Last Name:BUSTAMANTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:9135 RIDGELINE BLVD
Mailing Address - Street 2:SUITE #190
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-2391
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9135 RIDGELINE BLVD
Practice Address - Street 2:SUITE #190
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129-2391
Practice Address - Country:US
Practice Address - Phone:303-679-2017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2015-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODR.0052692207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO329521YMW9Medicare PIN