Provider Demographics
NPI:1578561692
Name:BUSHMAN, ROBERT EDWARD
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:BUSHMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8860 CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3068
Mailing Address - Country:US
Mailing Address - Phone:619-462-1670
Mailing Address - Fax:619-462-3209
Practice Address - Street 1:8860 CENTER DR
Practice Address - Street 2:STE 300
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3068
Practice Address - Country:US
Practice Address - Phone:619-462-1670
Practice Address - Fax:619-462-3209
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27334207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G273340Medicaid
CA00G273340Medicaid
CAWG27334AMedicare PIN