Provider Demographics
NPI:1427030469
Name:BUSTAMANTE, ERNESTINE (MD)
Entity Type:Individual
Prefix:DR
First Name:ERNESTINE
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 W FRYE RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-6255
Mailing Address - Country:US
Mailing Address - Phone:480-895-9555
Mailing Address - Fax:480-895-9494
Practice Address - Street 1:1950 W FRYE RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6255
Practice Address - Country:US
Practice Address - Phone:480-895-9555
Practice Address - Fax:480-961-2332
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30366207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ716996Medicaid
AZBB7954729OtherDEA
AZ716996Medicaid