Provider Demographics
NPI:1760407704
Name:BUSH, TERRY A (OD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:A
Last Name:BUSH
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 1:6606 S YALE AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3364
Mailing Address - Country:US
Mailing Address - Phone:918-492-4122
Mailing Address - Fax:918-492-7451
Practice Address - Street 1:6606 S YALE AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3364
Practice Address - Country:US
Practice Address - Phone:918-492-4122
Practice Address - Fax:918-492-7451
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2210152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1502210Medicaid
OK1502210Medicaid