Provider Demographics
NPI:1497375869
Name:BUSH, DEREK JAMES
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:JAMES
Last Name:BUSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 HUNTINGTON AVENUE
Mailing Address - Street 2:202 ROBINSON HALL
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:315-368-4674
Mailing Address - Fax:
Practice Address - Street 1:360 HUNTINGTON AVENUE
Practice Address - Street 2:202 ROBINSON HALL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:315-368-4674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-25
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program