Provider Demographics
NPI:1396108130
Name:CUSHMAN, GINA NICK (NMD)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:NICK
Last Name:CUSHMAN
Suffix:
Gender:F
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20072 SW BIRCH ST
Mailing Address - Street 2:240
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-0794
Mailing Address - Country:US
Mailing Address - Phone:949-715-9321
Mailing Address - Fax:
Practice Address - Street 1:20072 SW BIRCH ST
Practice Address - Street 2:240
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-0794
Practice Address - Country:US
Practice Address - Phone:949-715-9321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAND-145207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine