Provider Demographics
NPI:1326317207
Name:BUSAM, DAVID VINCENT (DPT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:VINCENT
Last Name:BUSAM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10475 READING RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-2563
Mailing Address - Country:US
Mailing Address - Phone:513-281-2278
Mailing Address - Fax:513-221-8219
Practice Address - Street 1:10475 READING RD
Practice Address - Street 2:SUITE 209
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45241-2563
Practice Address - Country:US
Practice Address - Phone:513-281-2278
Practice Address - Fax:513-221-8219
Is Sole Proprietor?:No
Enumeration Date:2011-12-21
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT10010225100000X
KY006017225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0063817Medicaid
KY7100207820Medicaid
KY7100207820Medicaid
KYK042910Medicare PIN
OH0063817Medicaid