Basic Information
| Provider Information | |||||||||
| NPI: | 1912485327 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZEGARRA BUSTAMANTE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ALEJANDRA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11513 LAKE UNDERHILL RD STE 220 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328255001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072491234 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1975 S JOHN YOUNG PKWY STE 204 | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347410603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072491234 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2018 | ||||||||
| LastUpdateDate: | 07/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME150504 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 110588000 | 05 | FL | MEDICAID |