Healthcare Provider Details

I. General information

NPI: 1912485327
Provider Name (Legal Business Name): MELISSA ALEJANDRA ZEGARRA BUSTAMANTE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 07/09/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 S JOHN YOUNG PKWY STE 204
KISSIMMEE FL
34741-0603
US

IV. Provider business mailing address

11513 LAKE UNDERHILL RD STE 220
ORLANDO FL
32825-5001
US

V. Phone/Fax

Practice location:
  • Phone: 407-249-1234
  • Fax:
Mailing address:
  • Phone: 407-249-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME150504
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: