Provider Demographics
NPI:1922127406
Name:BUSCH, STEPHEN M (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:M
Last Name:BUSCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2385 COLONY CROSSING PL
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4280
Mailing Address - Country:US
Mailing Address - Phone:804-739-2220
Mailing Address - Fax:804-739-2164
Practice Address - Street 1:2385 COLONY CROSSING PL
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4280
Practice Address - Country:US
Practice Address - Phone:804-739-2220
Practice Address - Fax:804-739-2164
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102037038174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADG4658OtherMEDICARE R/R
VA00W221C01Medicare ID - Type UnspecifiedPROVIDER #
VAE62122Medicare UPIN