Provider Demographics
NPI:1568483147
Name:RUSH, JOHN B (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:RUSH
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:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-1108
Mailing Address - Country:US
Mailing Address - Phone:541-247-7212
Mailing Address - Fax:541-247-0490
Practice Address - Street 1:94225 4TH STREET
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-7756
Practice Address - Country:US
Practice Address - Phone:541-247-7212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1111ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT68083Medicare ID - Type Unspecified
ORT68083Medicare UPIN