Provider Demographics
NPI:1457412801
Name:BHUSHAN, KOMALA N (MD)
Entity type:Individual
Prefix:DR
First Name:KOMALA
Middle Name:N
Last Name:BHUSHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:556 W BRITAIN ST
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:FL
Mailing Address - Zip Code:34442-8200
Mailing Address - Country:US
Mailing Address - Phone:352-527-2944
Mailing Address - Fax:
Practice Address - Street 1:512 N LECANTO HWY # 491
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-8547
Practice Address - Country:US
Practice Address - Phone:352-527-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME06580208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74732OtherBLUE SHIELD PROVIDER#
FL201205OtherAMERI GROUP
FL21644OtherHEALTHEASE & HEALTHYKIDS
FL270492700Medicaid
FL74732OtherBLUE SHIELD PROVIDER#