Provider Demographics
NPI:1063481661
Name:BUSH, ROGER A (OD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:A
Last Name:BUSH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-7243
Mailing Address - Country:US
Mailing Address - Phone:508-833-6000
Mailing Address - Fax:508-534-6060
Practice Address - Street 1:146 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-7243
Practice Address - Country:US
Practice Address - Phone:508-833-6000
Practice Address - Fax:508-534-6060
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3417152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110016133AMedicaid
MA0354058Medicaid
MAPX5040Medicare PIN
MAT59444Medicare UPIN
MA0354058Medicaid
MA110016133AMedicaid