Provider Demographics
NPI:1780678698
Name:BUSH, MICKEY VERNELL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICKEY
Middle Name:VERNELL
Last Name:BUSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:50 S B B KING BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2626
Mailing Address - Country:US
Mailing Address - Phone:901-436-1381
Mailing Address - Fax:
Practice Address - Street 1:3424 FM 1092 RD
Practice Address - Street 2:STE 220
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-2285
Practice Address - Country:US
Practice Address - Phone:281-208-3322
Practice Address - Fax:281-208-3393
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1780678698OtherBLUE CROSS BLUE SHIELD
TXP00936712OtherMEDICARE RR
TXP00941074OtherMEDICARE RR
C13996Medicare UPIN
TX1780678698OtherBLUE CROSS BLUE SHIELD
TXTXB105717Medicare PIN