Provider Demographics
NPI:1720037682
Name:VON DEM BUSSCHE, NICOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:
Last Name:VON DEM BUSSCHE
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:PO BOX 3095
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-0659
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:949-263-1639
Practice Address - Street 1:1 HOAG DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4162
Practice Address - Country:US
Practice Address - Phone:949-263-8620
Practice Address - Fax:949-263-1639
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA791782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A791780Medicaid
CA00A791780OtherBLUE SHIELD
CAP00346064OtherRR MEDICARE
CAI37949Medicare UPIN
CA00A791780Medicaid
CAP00346064OtherRR MEDICARE
CAWA79178EMedicare PIN