Provider Demographics
NPI:1871084723
Name:BUSHAW, JOHN JAMES IV (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JAMES
Last Name:BUSHAW
Suffix:IV
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 S ADAMS RD STE 201
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-7008
Mailing Address - Country:US
Mailing Address - Phone:248-644-8060
Mailing Address - Fax:
Practice Address - Street 1:800 S ADAMS RD STE 201
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-7008
Practice Address - Country:US
Practice Address - Phone:248-644-8060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-27
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4901005131152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program