Provider Demographics
NPI:1548202476
Name:BUSH, BRUCE RAYMOND (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:RAYMOND
Last Name:BUSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 CLOVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-1916
Mailing Address - Country:US
Mailing Address - Phone:562-809-6978
Mailing Address - Fax:
Practice Address - Street 1:814 CLOVERVIEW DR
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-1916
Practice Address - Country:US
Practice Address - Phone:562-809-6978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48195207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G481950Medicaid
CABJ395ZMedicare PIN
CAWG48195MMedicare PIN
CAWG48195Medicare PIN
CA00G481950Medicaid
CAHG48195Medicare PIN