Provider Demographics
NPI:1326049222
Name:BUSHKAR, JOHN PHILLIP (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PHILLIP
Last Name:BUSHKAR
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 1:127 MCCLANAHAN ST SW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-1728
Mailing Address - Country:US
Mailing Address - Phone:540-982-8204
Mailing Address - Fax:540-224-1059
Practice Address - Street 1:127 MCCLANAHAN ST SW
Practice Address - Street 2:SUITE 300
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1728
Practice Address - Country:US
Practice Address - Phone:540-982-8204
Practice Address - Fax:540-224-1059
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101017672207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5836018Medicaid
VACI6105OtherRR MEDICARE GROUP
VA5848911Medicaid
VACI6105OtherRR MEDICARE GROUP
VA060000984Medicare ID - Type Unspecified
VA060063554Medicare PIN
VAB07833Medicare UPIN