Healthcare Provider Details

I. General information

NPI: 1689657090
Provider Name (Legal Business Name): LARRY M BUSH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 S CONGRESS AVE STE 201
ATLANTIS FL
33462-6637
US

IV. Provider business mailing address

5401 S CONGRESS AVE STE 201
ATLANTIS FL
33462-6637
US

V. Phone/Fax

Practice location:
  • Phone: 561-967-0101
  • Fax: 561-967-6260
Mailing address:
  • Phone: 561-967-0101
  • Fax: 561-967-6260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberME0055230
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: