Provider Demographics
NPI:1124088968
Name:BUSTAMANTE, RUDOLPH (MD)
Entity type:Individual
Prefix:DR
First Name:RUDOLPH
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:PO BOX 10097
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85130-0020
Mailing Address - Country:US
Mailing Address - Phone:520-836-3446
Mailing Address - Fax:520-836-8807
Practice Address - Street 1:1856 E FLORENCE BLVD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5303
Practice Address - Country:US
Practice Address - Phone:520-381-0380
Practice Address - Fax:520-836-1826
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6500208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z137312OtherMEDICARE
AZ510984Medicaid
03-1881OtherMEDICARE
03-31815OtherMEDICARE
ZFQ31815OtherMEDICARE
03-31815OtherMEDICARE