MEDICARE: DR. CHARIS KAIULANI BUSH DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	20441	CA

General Provider Information

NPI Number	:	1679104335
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARIS KAIULANI BUSH DO

Provider Business Mailing Address
First Line	:	5767 W CENTURY BLVD STE 400
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-5631
Country	:	US
Telephone Number	:	310-301-8707
Fax Number	:

Provider Business Practice Location Address
First Line	:	1187 COAST VILLAGE RD STE 10A
Second Line	:
City	:	MONTECITO
State	:	CA
Zip	:	93108-2764
Country	:	US
Telephone Number	:	805-565-0020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2020
Last Update Date	:	08/01/2024

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