Provider Demographics
NPI:1407835937
Name:BAVUSO, SALVATORE KARL (MD)
Entity type:Individual
Prefix:DR
First Name:SALVATORE
Middle Name:KARL
Last Name:BAVUSO
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:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-1328
Mailing Address - Country:US
Mailing Address - Phone:804-435-8570
Mailing Address - Fax:
Practice Address - Street 1:36 LIVELY OAKS RD
Practice Address - Street 2:
Practice Address - City:LIVELY
Practice Address - State:VA
Practice Address - Zip Code:22507
Practice Address - Country:US
Practice Address - Phone:804-462-5155
Practice Address - Fax:804-462-5922
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1407835937Medicaid
VA410368OtherANTHEM BC/BS
VA410368OtherANTHEM BC/BS
VA1407835937Medicaid