Provider Demographics
NPI:1508182619
Name:BUSHMAN, JONATHAN K (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:K
Last Name:BUSHMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 W RANDOLPH AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-3834
Mailing Address - Country:US
Mailing Address - Phone:580-599-0272
Mailing Address - Fax:580-603-8602
Practice Address - Street 1:822 W RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-3834
Practice Address - Country:US
Practice Address - Phone:580-599-0272
Practice Address - Fax:580-603-8602
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2021-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5032207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKAAA3274OtherMEDICARE PTAN
OKOKAAA3276OtherMEDICARE PTAN
OK200395790AMedicaid
OKOKAAA3274OtherMEDICARE PTAN