MEDICARE: MR. ALFONSO ROBERT DENNIS BUSTOS

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	282N00000X	General Acute Care Hospital

General Provider Information

NPI Number	:	1659485795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALFONSO ROBERT DENNIS BUSTOS

Provider Business Mailing Address
First Line	:	5800 EUBANK BLVD NE APT 3024
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-6152
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5800 EUBANK BLVD NE APT 3024
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-6152
Country	:	US
Telephone Number	:	505-823-3423
Fax Number	:

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

Provider Enumeration Date	:	08/18/2006
Last Update Date	:	07/08/2007

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