Provider Demographics
NPI:1992857577
Name:TUSHLA, SCOTT J (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:J
Last Name:TUSHLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 OPUS DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-8649
Mailing Address - Country:US
Mailing Address - Phone:719-418-5505
Mailing Address - Fax:
Practice Address - Street 1:2993 BROADMOOR VALLEY RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4471
Practice Address - Country:US
Practice Address - Phone:719-418-5505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0042737207Q00000X
CAG86841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT40394FMedicaid
CA050394OtherBLUE CROSS
CA951683892OtherOTHER INSURANCE
CARHM08608FMedicaid
CAZZT40394FMedicaid
CA951683892OtherOTHER INSURANCE
CA050394OtherBLUE CROSS
CA951683892OtherOTHER INSURANCE
CA058553Medicare ID - Type UnspecifiedRH MEDICARE
CAZZT40394FMedicaid
CARHM08608FMedicaid
CA058608Medicare ID - Type UnspecifiedRH MEDICARE
CARHM08609FMedicaid