Provider Demographics
NPI:1609814011
Name:BUSHEY COLYER, JENNIFER LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LOUISE
Last Name:BUSHEY COLYER
Suffix:
Gender:F
Credentials:MD
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 OLIN WAY
Practice Address - Street 2:STE 2300
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-9243
Practice Address - Country:US
Practice Address - Phone:704-801-4577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00485208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
010092809OtherVA PREMIER
144083OtherANTHEM
78576OtherOPTIMA
VA010092809Medicaid
541778786001OtherTRICARE
NC5900054Medicaid
2129588OtherMDIPA/MAMSI
010092809OtherVA PREMIER