Provider Demographics
NPI:1558395681
Name:BUSHAN, LAKSHMI (MD)
Entity Type:Individual
Prefix:DR
First Name:LAKSHMI
Middle Name:
Last Name:BUSHAN
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 1:3434 HANCOCK BRIDGE PKWY
Mailing Address - Street 2:STE 301
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-7094
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2625
Practice Address - Street 1:4755 SUMMERLIN RD
Practice Address - Street 2:SUITE 8
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-1073
Practice Address - Country:US
Practice Address - Phone:239-275-5339
Practice Address - Fax:239-275-5595
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57213207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064857400Medicaid
FLME57213OtherMEDICAL LICENSE
FL064857400Medicaid