Provider Demographics
NPI:1609074319
Name:BUSHELL, IAN WILSON (MD, MHS-CL)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:WILSON
Last Name:BUSHELL
Suffix:
Gender:M
Credentials:MD, MHS-CL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 RESEARCH PARK BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-5842
Mailing Address - Country:US
Mailing Address - Phone:434-951-2485
Mailing Address - Fax:
Practice Address - Street 1:1000 RESEARCH PARK BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-5842
Practice Address - Country:US
Practice Address - Phone:434-951-2485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234098207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine