Provider Demographics
NPI:1518795764
Name:BUSIASHVILI, ERIC (DPT)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:BUSIASHVILI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10787 WILSHIRE BLVD APT 401
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-7339
Mailing Address - Country:US
Mailing Address - Phone:310-804-0082
Mailing Address - Fax:
Practice Address - Street 1:16573 VENTURA BLVD STE 5
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2021
Practice Address - Country:US
Practice Address - Phone:818-990-0868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306294225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist