1255365854 NPI number — DR. JEFFREY J BUSH M.D.

Table of content: DR. JEFFREY J BUSH M.D. (NPI 1255365854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255365854 NPI number — DR. JEFFREY J BUSH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSH
Provider First Name:
JEFFREY
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255365854
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2421 SLEEPY OAK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32720-8626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-738-9605
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2603 KURT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUSTIS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32726-6234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-483-6100
Provider Business Practice Location Address Fax Number:
352-483-6114
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  ME50643 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085U0001X , with the licence number: ME50643 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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