Provider Demographics
NPI:1154718807
Name:BUSHYHEAD, TIMOTHY
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:BUSHYHEAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 W ROGERS BLVD
Mailing Address - Street 2:
Mailing Address - City:SKIATOOK
Mailing Address - State:OK
Mailing Address - Zip Code:74070-3924
Mailing Address - Country:US
Mailing Address - Phone:918-396-4122
Mailing Address - Fax:918-403-6301
Practice Address - Street 1:1501 W ROGERS BLVD
Practice Address - Street 2:
Practice Address - City:SKIATOOK
Practice Address - State:OK
Practice Address - Zip Code:74070
Practice Address - Country:US
Practice Address - Phone:918-396-4122
Practice Address - Fax:918-403-6301
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5953207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine