Provider Demographics
NPI:1952812869
Name:BUSTAMANTE, ROBERT J
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
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 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1459
Mailing Address - Fax:360-729-3066
Practice Address - Street 1:770 E 11TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3746
Practice Address - Country:US
Practice Address - Phone:541-228-6425
Practice Address - Fax:541-338-1652
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist