Healthcare Provider Details

I. General information

NPI: 1902177231
Provider Name (Legal Business Name): JERRODL C BUSTOS MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15775 LAGUNA CANYON RD SUITE 120
IRVINE CA
92618-3189
US

IV. Provider business mailing address

5 HOLLAND STE 101
IRVINE CA
92618-2568
US

V. Phone/Fax

Practice location:
  • Phone: 949-588-2190
  • Fax: 949-588-2199
Mailing address:
  • Phone: 949-588-2190
  • Fax: 949-588-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberA85842
License Number StateCA

VIII. Authorized Official

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