MEDICARE: JORGE MARIO GOMEZ BUSTAMANTE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	19770	PR
2	208D00000X	General Practice Physician	ACN980	FL

General Provider Information

NPI Number	:	1184133050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORGE MARIO GOMEZ BUSTAMANTE MD

Provider Business Mailing Address
First Line	:	8333 NW 53RD ST FL 6
Second Line	:
City	:	DORAL
State	:	FL
Zip	:	33166-4783
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	823 S PARSONS AVE
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-6063
Country	:	US
Telephone Number	:	813-662-4841
Fax Number	:	813-743-3111

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2017
Last Update Date	:	06/01/2026

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