Provider Demographics
NPI:1326367988
Name:BUSH, DIANA M (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:BUSH
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 1:123 FRANKLIN CORNER RD
Mailing Address - Street 2:STE 216
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2526
Mailing Address - Country:US
Mailing Address - Phone:609-815-7270
Mailing Address - Fax:
Practice Address - Street 1:123 FRANKLIN CORNER RD STE 216
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2526
Practice Address - Country:US
Practice Address - Phone:609-815-7270
Practice Address - Fax:609-815-7271
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD449604207Q00000X
NJ25MA09738100207Q00000X
PAMT197012390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program