Provider Demographics
NPI:1942454210
Name:BUSHKIN, FREDERIC L (MD)
Entity Type:Individual
Prefix:
First Name:FREDERIC
Middle Name:L
Last Name:BUSHKIN
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:3800 JOHNSON ST
Practice Address - Street 2:SECOND FLOOR, SUITE E
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6030
Practice Address - Country:US
Practice Address - Phone:954-985-9336
Practice Address - Fax:954-985-9338
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME21234208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL91698OtherBCBS
FL000562000Medicaid
FL4068300OtherAETNA
FL961642OtherWELLCARE
FLP971336OtherOPTIMUM
FL1666861OtherCIGNA
FL208599OtherAVMED
FL8902OtherDIMENSION
FLP1035576OtherFREEDOM
FLQMP0000004939254OtherMOLINA
FLQMP0000004939254OtherMOLINA
FL78884XMedicare PIN