Provider Demographics
NPI:1295803054
Name:BUSH, DAVID SAMUEL (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:SAMUEL
Last Name:BUSH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11211 PROSPERITY FARMS ROAD
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-3401
Mailing Address - Country:US
Mailing Address - Phone:561-622-8881
Mailing Address - Fax:
Practice Address - Street 1:11211 PROSPERITY FARMS ROAD
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-3401
Practice Address - Country:US
Practice Address - Phone:561-622-8881
Practice Address - Fax:561-622-8018
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY003425103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75751AMedicare ID - Type Unspecified