Provider Demographics
NPI:1063425791
Name:BUSCH, FORREST K JR (DO)
Entity type:Individual
Prefix:MR
First Name:FORREST
Middle Name:K
Last Name:BUSCH
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:710 HWY 51 BYPASS
Mailing Address - Street 2:PMB 363
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024
Mailing Address - Country:US
Mailing Address - Phone:731-286-4300
Mailing Address - Fax:731-286-8008
Practice Address - Street 1:1950 COOK ST
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024
Practice Address - Country:US
Practice Address - Phone:731-286-4300
Practice Address - Fax:731-286-8008
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNDO0000000839208D00000X, 207K00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3303355Medicaid
TN070009417OtherRAILROAD MEDICARE
TNE34164Medicare UPIN