Provider Demographics
NPI:1922327345
Name:BUSH, JOE BLAZ (MED)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:BLAZ
Last Name:BUSH
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:BLAZ
Other - Middle Name:
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:122 E EUFAULA ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6017
Mailing Address - Country:US
Mailing Address - Phone:405-447-4499
Mailing Address - Fax:
Practice Address - Street 1:122 E EUFAULA ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6017
Practice Address - Country:US
Practice Address - Phone:405-447-4499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator