Provider Demographics
NPI:1245506773
Name:BUSTAMANTE, NIRMA D
Entity type:Individual
Prefix:
First Name:NIRMA
Middle Name:D
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79930-1718
Mailing Address - Country:US
Mailing Address - Phone:915-726-0666
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-732-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU4161207P00000X
390200000X
MA251934207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program