=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437183068
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LETANTIA B BUSSELL M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 06/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 433 N CAMDEN DR SUITE 805
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90210-4409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-550-7661
-----------------------------------------------------
Fax | 310-550-1920
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 433 N CAMDEN DR SUITE 805
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90210-4409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-550-7661
-----------------------------------------------------
Fax | 310-550-1920
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | G30563
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------