Healthcare Provider Details

I. General information

NPI: 1780723577
Provider Name (Legal Business Name): RATHNA BUSHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1454 MADISON AVE W
IMMOKALEE FL
34142-2200
US

IV. Provider business mailing address

11341 LONGWATER CHASE COURT
FORT MYERS FL
33908
US

V. Phone/Fax

Practice location:
  • Phone: 239-965-8300
  • Fax: 239-658-3175
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME55449
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: