Provider Demographics
NPI:1720199227
Name:BUSTAMANTE, ANDRES
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2702
Mailing Address - Country:US
Mailing Address - Phone:619-426-9610
Mailing Address - Fax:619-426-8737
Practice Address - Street 1:227 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2702
Practice Address - Country:US
Practice Address - Phone:619-426-9610
Practice Address - Fax:619-426-8737
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70351207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A703510Medicaid
CAA70351Medicare ID - Type Unspecified
CA00A703510Medicaid