1679537435 NPI number — JORGE BUSTILLO M.D.

Table of content: JORGE BUSTILLO M.D. (NPI 1679537435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679537435 NPI number — JORGE BUSTILLO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSTILLO
Provider First Name:
JORGE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679537435
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 BERNVILLE ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
READING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19605-9453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-378-2000
Provider Business Mailing Address Fax Number:
610-378-2799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2494 BERNVILLE ROAD
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
READING
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19605-9469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-378-2996
Provider Business Practice Location Address Fax Number:
610-208-8812
Provider Enumeration Date:
04/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  D0078545 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: MD421803 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 580344 . This is a "MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0019586400010 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 745419800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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