Provider Demographics
NPI:1255667184
Name:BAVUSO, NICOLE T (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:T
Last Name:BAVUSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S 8TH ST
Mailing Address - Street 2:DUNCAN BUILDING, SUITE 3D
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-4000
Mailing Address - Country:US
Mailing Address - Phone:215-829-6797
Mailing Address - Fax:
Practice Address - Street 1:301 S 8TH ST
Practice Address - Street 2:DUNCAN BUILDING, SUITE 3D
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-4000
Practice Address - Country:US
Practice Address - Phone:215-829-6797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD449423207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology