Provider Demographics
NPI:1689657090
Name:BUSH, LARRY M (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:M
Last Name:BUSH
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 1:5401 S CONGRESS AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:ATLANTIS
Mailing Address - State:FL
Mailing Address - Zip Code:33462-6637
Mailing Address - Country:US
Mailing Address - Phone:561-967-0101
Mailing Address - Fax:561-967-6260
Practice Address - Street 1:5401 S CONGRESS AVE STE 201
Practice Address - Street 2:
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-6637
Practice Address - Country:US
Practice Address - Phone:561-967-0101
Practice Address - Fax:561-967-6260
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0055230207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL036606400Medicaid
FLC32521Medicare UPIN
FL55230Medicare PIN