Provider Demographics
NPI:1457464257
Name:BUSH, JERRY OTIS (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:OTIS
Last Name:BUSH
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 1:1000 WELLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501
Mailing Address - Country:US
Mailing Address - Phone:970-243-9000
Mailing Address - Fax:970-245-4936
Practice Address - Street 1:1000 WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501
Practice Address - Country:US
Practice Address - Phone:970-243-9000
Practice Address - Fax:970-245-4936
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26622207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01266220Medicaid
AB1100231OtherDEA
AB1100231OtherDEA
CO0454430001Medicare NSC
CO66134Medicare PIN
66134Medicare ID - Type Unspecified