Provider Demographics
NPI:1912485327
Name:ZEGARRA BUSTAMANTE, MELISSA ALEJANDRA (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ALEJANDRA
Last Name:ZEGARRA BUSTAMANTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11513 LAKE UNDERHILL RD STE 220
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-5001
Mailing Address - Country:US
Mailing Address - Phone:407-249-1234
Mailing Address - Fax:
Practice Address - Street 1:1975 S JOHN YOUNG PKWY STE 204
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-0603
Practice Address - Country:US
Practice Address - Phone:407-249-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME150504208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110588000Medicaid