Provider Demographics
NPI:1851644090
Name:GUSTAVO BUSTAMANTE MD PA
Entity Type:Organization
Organization Name:GUSTAVO BUSTAMANTE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSTAMANTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-841-8925
Mailing Address - Street 1:500 DELANEY AVE
Mailing Address - Street 2:402
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-3850
Mailing Address - Country:US
Mailing Address - Phone:407-841-8925
Mailing Address - Fax:
Practice Address - Street 1:500 DELANEY AVE
Practice Address - Street 2:402
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-3850
Practice Address - Country:US
Practice Address - Phone:407-841-8925
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24981261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical