Provider Demographics
NPI:1003070111
Name:BUSH, ROBERT JOEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOEL
Last Name:BUSH
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 1:750 N FREEDOM BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1690
Mailing Address - Country:US
Mailing Address - Phone:801-852-1443
Mailing Address - Fax:
Practice Address - Street 1:750 N FREEDOM BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1690
Practice Address - Country:US
Practice Address - Phone:801-852-1443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10761618-1205207QA0401X
MDD74498207QA0401X
IN016065704A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAVAD 000Medicare UPIN