Basic Information
| Provider Information | |||||||||
| NPI: | 1962446914 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUSKA | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1941 NEW GARDEN RD STE 216 | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274102555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362888857 | ||||||||
| FaxNumber: | 3362888769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 10/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34563 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0101250 | 01 | NC | UNITED HEALTHCARE | OTHER | 010055306 | 01 | NC | RAILROAD MEDICARE | OTHER | 4503048 | 01 | NC | AETNA | OTHER | 7917062 | 05 | NC | MEDICAID | 7279468 | 01 | NC | CIGNA | OTHER | 17062 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 46129 | 01 | NC | MEDCOST, LLC | OTHER |