Healthcare Provider Details

I. General information

NPI: 1578561692
Provider Name (Legal Business Name): DR. ROBERT EDWARD BUSHMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 01/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8860 CENTER DR STE 300
LA MESA CA
91942-3068
US

IV. Provider business mailing address

8860 CENTER DR STE 300
LA MESA CA
91942-3068
US

V. Phone/Fax

Practice location:
  • Phone: 619-462-1670
  • Fax: 619-462-3209
Mailing address:
  • Phone: 619-462-1670
  • Fax: 619-462-3209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG27334
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: