Provider Demographics
NPI:1437191566
Name:BUSH, WALTER RICHARD JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:RICHARD
Last Name:BUSH
Suffix:JR
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:PO BOX 661748
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-1748
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:5925 SAN VICENTE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-6630
Practice Address - Country:US
Practice Address - Phone:323-932-5105
Practice Address - Fax:323-932-5356
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77957207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G779570Medicaid
CAWG77957Medicare ID - Type Unspecified
CA00G779570Medicaid
CA00G779570Medicare PIN
CAWG77957FMedicare PIN
CAWG77957GMedicare PIN