Provider Demographics
NPI:1912940891
Name:BUSH, JON DAMON (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:DAMON
Last Name:BUSH
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:PO BOX 2533
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79105-2533
Mailing Address - Country:US
Mailing Address - Phone:806-212-6965
Mailing Address - Fax:806-212-6278
Practice Address - Street 1:1600 WALLACE BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1799
Practice Address - Country:US
Practice Address - Phone:806-212-2129
Practice Address - Fax:806-212-6278
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6002207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164308203Medicaid
TX270280YM5UMedicare UPIN