Basic Information
| Provider Information | |||||||||
| NPI: | 1902017007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSH | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 W EXCHANGE ST | ||||||||
| Address2: | |||||||||
| City: | SPRING LAKE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494562024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168460620 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | G3525 S SAGINAW ST | ||||||||
| Address2: | |||||||||
| City: | BURTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485291260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102326031 | ||||||||
| FaxNumber: | 8102326041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 11/02/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901002444 | MI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 5191166 | 05 | MI | MEDICAID | 4901002444 | 01 | MI | LICENSE | OTHER |