Basic Information
| Provider Information | |||||||||
| NPI: | 1871568402 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSTAMANTE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 W MONROE ST | ||||||||
| Address2: | STE 1200 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606032420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127339730 | ||||||||
| FaxNumber: | 7738668014 | ||||||||
| Practice Location | |||||||||
| Address1: | 6401 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462196614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178087085 | ||||||||
| FaxNumber: | 3177080115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 05/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01072053A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 4301054000 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35.134395 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.