Provider Demographics
NPI:1942251384
Name:BUSTOS, JERROLD C (MD)
Entity Type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:C
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 1:394 S LOS ROBLES AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3298
Mailing Address - Country:US
Mailing Address - Phone:626-584-6370
Mailing Address - Fax:
Practice Address - Street 1:830 S. CITRUS AVENUE
Practice Address - Street 2:SUITE #201
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702
Practice Address - Country:US
Practice Address - Phone:626-974-1441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85842207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA85842OtherCA, MEDICAL LICENSE
CAA85842OtherCA, MEDICAL LICENSE
CAI52607Medicare UPIN