Provider Demographics
NPI:1790891208
Name:BHUSHAN, SUSAN D (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:BHUSHAN
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 1:4976 ALPHA LN
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-5470
Mailing Address - Country:US
Mailing Address - Phone:423-308-0280
Mailing Address - Fax:423-308-0281
Practice Address - Street 1:4980 ALPHA LN
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-5470
Practice Address - Country:US
Practice Address - Phone:423-870-2450
Practice Address - Fax:423-877-5208
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000030744207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3891480Medicaid
TN4105104OtherBCBST
TN38914801OtherMEDICARE-ID TYPE UNSPECIFIED
TN38914801Medicaid