Healthcare Provider Details

I. General information

NPI: 1124088968
Provider Name (Legal Business Name): RUDOLPH BUSTAMANTE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1856 E FLORENCE BLVD
CASA GRANDE AZ
85122-5303
US

IV. Provider business mailing address

PO BOX 10097
CASA GRANDE AZ
85130-0020
US

V. Phone/Fax

Practice location:
  • Phone: 520-381-0380
  • Fax: 520-836-1826
Mailing address:
  • Phone: 520-836-3446
  • Fax: 520-836-8807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6500
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: