Healthcare Provider Details

I. General information

NPI: 1548551930
Provider Name (Legal Business Name): JERROLD C BUSTOS MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 SAN FERNANDO RD
GLENDALE CA
91202-2104
US

IV. Provider business mailing address

5 HOLLAND STE 101
IRVINE CA
92618-2568
US

V. Phone/Fax

Practice location:
  • Phone: 818-637-7766
  • Fax: 818-956-1706
Mailing address:
  • Phone: 949-588-2190
  • Fax: 949-588-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA85842
License Number StateCA

VIII. Authorized Official

Name: JERROLD C BUSTOS
Title or Position: PRESIDENT
Credential: MD
Phone: 949-588-2190