Basic Information
| Provider Information | |||||||||
| NPI: | 1467728857 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKSHMI BUSHAN MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4755 SUMMERLIN RD | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339191073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392755339 | ||||||||
| FaxNumber: | 2392755595 | ||||||||
| Practice Location | |||||||||
| Address1: | 4755 SUMMERLIN RD | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339191073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392755339 | ||||||||
| FaxNumber: | 2392755595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 03/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | BUSHAN | ||||||||
| AuthorizedOfficialFirstName: | LAKSHMI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2392755339 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | ME57213 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 064857400 | 05 | FL | MEDICAID |