Provider Demographics
NPI:1316258874
Name:BUSH, SHANE DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:DAVID
Last Name:BUSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 WILLOWCREEK RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5075
Mailing Address - Country:US
Mailing Address - Phone:219-707-1185
Mailing Address - Fax:
Practice Address - Street 1:3630 WILLOWCREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5075
Practice Address - Country:US
Practice Address - Phone:219-364-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071914A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine