Provider Demographics
NPI:1497840839
Name:BUSTAMANTE, ALFONSO (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ALFONSO
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 PARK COURT PL
Mailing Address - Street 2:SUITE E 102
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-5002
Mailing Address - Country:US
Mailing Address - Phone:714-724-7412
Mailing Address - Fax:
Practice Address - Street 1:1801 PARK COURT PL
Practice Address - Street 2:SUITE E 102
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-5002
Practice Address - Country:US
Practice Address - Phone:714-724-7412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17114103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical