Provider Demographics
NPI:1598009722
Name:JEFFERY B BUSHMAN DO PC
Entity Type:Organization
Organization Name:JEFFERY B BUSHMAN DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:BURL
Authorized Official - Last Name:BUSHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:D O
Authorized Official - Phone:520-384-4291
Mailing Address - Street 1:PO BOX 1115
Mailing Address - Street 2:905 N BOWIE AVE
Mailing Address - City:WILLCOX
Mailing Address - State:AZ
Mailing Address - Zip Code:85644-1115
Mailing Address - Country:US
Mailing Address - Phone:520-384-4291
Mailing Address - Fax:520-384-3055
Practice Address - Street 1:905 N BOWIE AVE
Practice Address - Street 2:
Practice Address - City:WILLCOX
Practice Address - State:AZ
Practice Address - Zip Code:85643-1145
Practice Address - Country:US
Practice Address - Phone:520-384-4291
Practice Address - Fax:520-384-3055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-10
Last Update Date:2012-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2338302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ277047Medicaid