Provider Demographics
NPI:1982692158
Name:BUSTAMANTE, GUADALUPE (MD)
Entity Type:Individual
Prefix:DR
First Name:GUADALUPE
Middle Name:
Last Name: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 1:4007 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4605
Mailing Address - Country:US
Mailing Address - Phone:773-767-2266
Mailing Address - Fax:773-767-3933
Practice Address - Street 1:4007 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4605
Practice Address - Country:US
Practice Address - Phone:773-767-2266
Practice Address - Fax:773-767-4380
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088384207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088384Medicaid
ILL86323Medicare PIN
IL036088384Medicaid