Provider Demographics
NPI:1841602117
Name:BUSTAMANTE BERNAL, MARCO ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:ANTONIO
Last Name:BUSTAMANTE BERNAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 W HAGUE RD
Mailing Address - Street 2:STE 590
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-5808
Mailing Address - Country:US
Mailing Address - Phone:915-532-1620
Mailing Address - Fax:915-544-3852
Practice Address - Street 1:125 W HAGUE RD
Practice Address - Street 2:STE 590
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-5808
Practice Address - Country:US
Practice Address - Phone:915-532-1620
Practice Address - Fax:915-544-3852
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR4017207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX382214002Medicaid