Provider Demographics
NPI:1134411333
Name:BUSTAMANTE, DANIEL (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:BUSTAMANTE
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 1:440 RAYNOLDS ST.
Mailing Address - Street 2:MSC51015
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4815 ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-7990
Practice Address - Country:US
Practice Address - Phone:915-215-4956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ7658207ZP0102X, 207ZH0000X
NMMD2014-0816207ZP0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program