Healthcare Provider Details

I. General information

NPI: 1912402884
Provider Name (Legal Business Name): CHRISTIAN EDGAR BUSTAMANTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2018
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NMRTC/NAVAL HOSPITAL YOKOSUKA JAPAN INAOKACHO, 82
YOKOSUKA KANAGAWA
238-0001
JP

IV. Provider business mailing address

2523 12TH SQ SW
VERO BEACH FL
32968-5065
US

V. Phone/Fax

Practice location:
  • Phone: 46-816-7144
  • Fax:
Mailing address:
  • Phone: 772-559-2206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberS6580
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME145628
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: