Provider Demographics
NPI:1023021045
Name:BUSHONG, CHARLES ROBERT JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROBERT
Last Name:BUSHONG
Suffix:JR
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 1:16 POCONO RD
Mailing Address - Street 2:SUITE 214
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2901
Mailing Address - Country:US
Mailing Address - Phone:973-627-6129
Mailing Address - Fax:
Practice Address - Street 1:16 POCONO RD
Practice Address - Street 2:SUITE 214
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2901
Practice Address - Country:US
Practice Address - Phone:973-627-6129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2015-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03472800208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics