MEDICARE: GAUTAM BULUSU BS

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1427996826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAUTAM BULUSU BS

Provider Business Mailing Address
First Line	:	8700 BEVERLY BLVD STE 8215NT
Second Line	:
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90048-1804
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8700 BEVERLY BLVD STE 8215NT
Second Line	:
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90048-1804
Country	:	US
Telephone Number	:	310-423-3277
Fax Number	:

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

Provider Enumeration Date	:	03/24/2026
Last Update Date	:	03/24/2026

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