Provider Demographics
NPI:1063404200
Name:BUSCH, KENNETH JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAMES
Last Name:BUSCH
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 1:2119 E SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7503
Mailing Address - Country:US
Mailing Address - Phone:480-831-1844
Mailing Address - Fax:480-383-2685
Practice Address - Street 1:2119 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7503
Practice Address - Country:US
Practice Address - Phone:480-831-1844
Practice Address - Fax:480-383-2685
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2012-12-13
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
AZ8573207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology