Provider Demographics
NPI:1902196330
Name:BUSTOS, JERAMIAH (MD)
Entity Type:Individual
Prefix:
First Name:JERAMIAH
Middle Name:
Last Name:BUSTOS
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 1:816 ESTANCIA DR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-1362
Mailing Address - Country:US
Mailing Address - Phone:505-514-9498
Mailing Address - Fax:
Practice Address - Street 1:933 BRADBURY DR SE
Practice Address - Street 2:SUITE 2222
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4374
Practice Address - Country:US
Practice Address - Phone:505-272-3120
Practice Address - Fax:505-272-8060
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2014-0082207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1902196330Medicare PIN