Provider Demographics
NPI:1366495640
Name:BUSCEMA, CHARLES A (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:BUSCEMA
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 1:7400 LAURELS PL
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3268
Mailing Address - Country:US
Mailing Address - Phone:772-618-0505
Mailing Address - Fax:772-618-4692
Practice Address - Street 1:266 NW PEACOCK BLVD STE 102
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2271
Practice Address - Country:US
Practice Address - Phone:772-618-0505
Practice Address - Fax:772-618-4692
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130769-22084F0202X
FLME975042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB81671Medicare UPIN
NY55164AMedicare ID - Type UnspecifiedGROUP MEDICARE NUMBER