Provider Demographics
NPI:1346215860
Name:BUSHBERG, DAVID A (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:BUSHBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GRAND BLVD
Mailing Address - Street 2:SUITE 112, PMB 491
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-5955
Mailing Address - Country:US
Mailing Address - Phone:787-761-6093
Mailing Address - Fax:787-761-6053
Practice Address - Street 1:100 GRAND BLVD
Practice Address - Street 2:GALERIA PASEOS MALL SUITE 106-A
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-5955
Practice Address - Country:US
Practice Address - Phone:787-761-6093
Practice Address - Fax:787-761-6053
Is Sole Proprietor?:No
Enumeration Date:2006-02-19
Last Update Date:2009-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH79265Medicare UPIN
PR89055Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER