=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033171228
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID MICHAEL BUSH M.D., PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2006
-----------------------------------------------------
Last Update Date | 12/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5282 MEDICAL DR STE 614
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-6115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-644-4600
-----------------------------------------------------
Fax | 210-702-6962
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 903 W MARTIN ST # MS 49-2
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78207-0903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-358-5909
-----------------------------------------------------
Fax | 210-358-5940
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0202X
-----------------------------------------------------
Taxonomy Name | Pediatric Cardiology Physician
-----------------------------------------------------
License Number | M1548
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------