Provider Demographics
NPI:1801823893
Name:LUSH, DAVID T (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:T
Last Name:LUSH
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 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-764-3000
Mailing Address - Fax:
Practice Address - Street 1:3811 VALLEY CENTRE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3318
Practice Address - Country:US
Practice Address - Phone:858-764-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG175810207R00000X
PAMD022085E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010409250001Medicaid
PA1010409250001Medicaid
PA937653Medicare PIN