Provider Demographics
NPI:1366422099
Name:BUSHONG, REBECCA L (MD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:L
Last Name:BUSHONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1601 LAFAYETTE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-1032
Mailing Address - Country:US
Mailing Address - Phone:765-362-1212
Mailing Address - Fax:765-361-0210
Practice Address - Street 1:1601 LAFAYETTE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-1032
Practice Address - Country:US
Practice Address - Phone:765-362-1212
Practice Address - Fax:765-361-0210
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015967174400000X
OH35050655174400000X
IN01036464A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INB28580Medicare UPIN
IN187490HMedicare PIN