Provider Demographics
NPI:1861596231
Name:BUSH, OLIVIA D (MD)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:D
Last Name:BUSH
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 1:6255 W SUNSET BLVD FL 21
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7422
Mailing Address - Country:US
Mailing Address - Phone:323-860-5200
Mailing Address - Fax:323-467-7119
Practice Address - Street 1:20 CLAIBORNE TRL
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-6745
Practice Address - Country:US
Practice Address - Phone:404-388-1017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTPME3832207R00000X
GA033544207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E80684Medicare UPIN
11BDDFJMedicare ID - Type Unspecified