Provider Demographics
NPI:1083775613
Name:BUSHNELL, BRENT A (IDC)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:A
Last Name:BUSHNELL
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 814 BOX 19
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09865
Mailing Address - Country:GR
Mailing Address - Phone:011302822-102-1590
Mailing Address - Fax:01130282-102-1589
Practice Address - Street 1:PSC 814 BOX 19
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09865
Practice Address - Country:GR
Practice Address - Phone:011302822-102-1590
Practice Address - Fax:01130282-102-1589
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman