Provider Demographics
NPI:1417142837
Name:BUSHINGER, SCOTT J (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:J
Last Name:BUSHINGER
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 1:5792 WIDEWATERS PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1847
Mailing Address - Country:US
Mailing Address - Phone:315-422-4412
Mailing Address - Fax:
Practice Address - Street 1:5792 WIDEWATERS PKWY STE 101
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1847
Practice Address - Country:US
Practice Address - Phone:315-422-4412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007211-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400005790Medicare PIN