Provider Demographics
NPI:1891747234
Name:BUSH, MICHAEL E (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
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 1:3017 WEST AVE.
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601
Mailing Address - Country:US
Mailing Address - Phone:319-752-1400
Mailing Address - Fax:319-752-1401
Practice Address - Street 1:3017 WEST AVE.
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601
Practice Address - Country:US
Practice Address - Phone:319-752-1400
Practice Address - Fax:319-752-1401
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02028152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0129478Medicaid
IAU53348Medicare UPIN
IA00350Medicare ID - Type Unspecified