Provider Demographics
NPI:1669488979
Name:BUSHARDT, LISA C (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:BUSHARDT
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-261-3737
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:105 THORNHILL DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1548
Practice Address - Country:US
Practice Address - Phone:601-261-3737
Practice Address - Fax:601-261-3899
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12307207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00012749Medicaid
110028735OtherRAILROAD MEDICARE
MS1558923OtherAMERICAN ADMIN GROUP
LA1419877Medicaid
MS00012749Medicaid
MS1558923OtherAMERICAN ADMIN GROUP