Healthcare Provider Details

I. General information

NPI: 1598009722
Provider Name (Legal Business Name): JEFFERY B BUSHMAN DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2012
Last Update Date: 11/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 N BOWIE AVE
WILLCOX AZ
85643-1145
US

IV. Provider business mailing address

PO BOX 1115 905 N BOWIE AVE
WILLCOX AZ
85644-1115
US

V. Phone/Fax

Practice location:
  • Phone: 520-384-4291
  • Fax: 520-384-3055
Mailing address:
  • Phone: 520-384-4291
  • Fax: 520-384-3055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number2338
License Number StateAZ

VIII. Authorized Official

Name: DR. JEFFERY BURL BUSHMAN
Title or Position: OWNER/PHYSICIAN
Credential: D. O.
Phone: 520-384-4291