Healthcare Provider Details

I. General information

NPI: 1265781090
Provider Name (Legal Business Name): JONATHAN P BUSHMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1728 CLARKSON RD SUITE D
CHESTERFIELD MO
63017-4976
US

IV. Provider business mailing address

6 VICTORY DRIVE
LIBERTY MO
64068-1972
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-8258
  • Fax: 314-821-3476
Mailing address:
  • Phone: 816-883-2660
  • Fax: 816-792-9819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2007028938
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: