Provider Demographics
NPI:1902017007
Name:BUSH, DAVID H (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:H
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 1:105 W EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-2024
Mailing Address - Country:US
Mailing Address - Phone:616-846-0620
Mailing Address - Fax:
Practice Address - Street 1:G3525 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48529-1260
Practice Address - Country:US
Practice Address - Phone:810-232-6031
Practice Address - Fax:810-232-6041
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002444152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5191166Medicaid
MI4901002444OtherLICENSE
MI0P32620Medicare PIN
MI4901002444OtherLICENSE
MI5191166Medicaid