Provider Demographics
NPI:1861451247
Name:KAVURU, BUSH (MD)
Entity Type:Individual
Prefix:
First Name:BUSH
Middle Name:
Last Name:KAVURU
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 1:1705 TARBORO ST SW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-3428
Mailing Address - Country:US
Mailing Address - Phone:252-399-8040
Mailing Address - Fax:252-399-8829
Practice Address - Street 1:1705 TARBORO ST SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3428
Practice Address - Country:US
Practice Address - Phone:252-399-8040
Practice Address - Fax:252-399-8829
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97-01789174400000X
VA0101-2428422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891157UMedicaid
NC891157UMedicaid
VA017059C19Medicare PIN
NCG86716Medicare UPIN