=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992857577
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT J TUSHLA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2007
-----------------------------------------------------
Last Update Date | 02/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2993 BROADMOOR VALLEY RD
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80906-4471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-418-5505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4711 OPUS DR
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80906-8649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-418-5505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | DR.0042737
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------