Provider Demographics
NPI:1184133050
Name:GOMEZ BUSTAMANTE, JORGE MARIO (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:MARIO
Last Name:GOMEZ 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 1:10508 GIBSONTON DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-5434
Mailing Address - Country:US
Mailing Address - Phone:855-226-6633
Mailing Address - Fax:
Practice Address - Street 1:10508 GIBSONTON DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-5434
Practice Address - Country:US
Practice Address - Phone:855-226-6633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-23
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19770208D00000X
FLACN980208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice