Provider Demographics
NPI:1265604656
Name:GUSHWA, RICHARD L (DO)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:GUSHWA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12734 KENWOOD LN
Mailing Address - Street 2:STE. 84
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-5666
Mailing Address - Country:US
Mailing Address - Phone:239-936-5250
Mailing Address - Fax:239-936-9970
Practice Address - Street 1:12734 KENWOOD LN
Practice Address - Street 2:STE. 84
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5666
Practice Address - Country:US
Practice Address - Phone:239-936-5250
Practice Address - Fax:239-936-9970
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 55782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry