Provider Demographics
NPI:1194068437
Name:BUSHMAN, TROY JAY (DO)
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:JAY
Last Name:BUSHMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 741716
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3200 CHANNING WAY STE 306
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7546
Practice Address - Country:US
Practice Address - Phone:208-535-4400
Practice Address - Fax:208-535-4404
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1521208100000X
AZ007103208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation