Basic Information
| Provider Information | |||||||||
| NPI: | 1841226735 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSHARA | ||||||||
| FirstName: | KHALAFALLA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.B., B.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
| Address2: | 420 DELAWARE STREET SE, MMC 295 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126246666 | ||||||||
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| Practice Location | |||||||||
| Address1: | UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
| Address2: | 516 DELAWARE STREET SE, PWB FIRST FLOOR, CLINIC 1A | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126263004 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 44165 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | HP34287 | 01 | MN | HEALTHPARTNERS | OTHER | 1518044 | 01 | MN | ARAZ | OTHER | 05-00449 | 01 | MN | MEDICA CHOICE | OTHER | 1029761 | 01 | MN | PREFERRED ONE | OTHER | 397R2BU | 01 | MN | BCBS | OTHER | 141527 | 01 | MN | UCARE | OTHER |