Provider Demographics
NPI:1679701361
Name:BUSHYHEAD, IAN DOW (DO)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:DOW
Last Name:BUSHYHEAD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:14601 E 88TH PL N STE 308
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4966
Mailing Address - Country:US
Mailing Address - Phone:918-528-4733
Mailing Address - Fax:918-528-4739
Practice Address - Street 1:14601 E 88TH PL N STE 308
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4966
Practice Address - Country:US
Practice Address - Phone:918-528-4733
Practice Address - Fax:918-528-4739
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4743207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine