Provider Demographics
NPI:1467400952
Name:RUSH, NICOLE A (OD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:A
Last Name:RUSH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RUSH
Other - Last Name:ERENFELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:P.O. BOX 956
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411
Mailing Address - Country:US
Mailing Address - Phone:541-347-3622
Mailing Address - Fax:541-347-2872
Practice Address - Street 1:1095 ALABAMA AVE.
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411
Practice Address - Country:US
Practice Address - Phone:541-347-3622
Practice Address - Fax:541-347-2872
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2856ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227958Medicaid
ORR113367Medicare PIN
OR227958Medicaid