Provider Demographics
NPI:1982697074
Name:BULUSU, ADITYA D (MD)
Entity type:Individual
Prefix:
First Name:ADITYA
Middle Name:D
Last Name:BULUSU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48601-2558
Mailing Address - Country:US
Mailing Address - Phone:989-791-4020
Mailing Address - Fax:989-921-8765
Practice Address - Street 1:1117 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-2558
Practice Address - Country:US
Practice Address - Phone:989-791-4020
Practice Address - Fax:989-921-8765
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIAB076885208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI340019505OtherTRI CARE
MI4279350Medicaid
MI0990537OtherHEALTHPLUS-BAY
MI0990461OtherHEALTHPLUS-SAGINAW
MI340G310500OtherBLUE CROSS
MI5272733OtherAETNA
MI340019505OtherRAILROAD MEDICARE
MIG94169Medicare UPIN
MI340019505OtherRAILROAD MEDICARE