Provider Demographics
NPI:1821301763
Name:BUSH, SARA ROSE (OD)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:ROSE
Last Name:BUSH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SARA
Other - Middle Name:ROSE
Other - Last Name:PAVLIK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1124 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-2256
Mailing Address - Country:US
Mailing Address - Phone:231-591-2020
Mailing Address - Fax:
Practice Address - Street 1:1124 S STATE ST
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2256
Practice Address - Country:US
Practice Address - Phone:231-591-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004593152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E47602OtherBLUE CROSS
MI0E47602OtherBLUE CROSS