Basic Information
| Provider Information | |||||||||
| NPI: | 1043375405 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSHNELL | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | ELLIOT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50095 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981455095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065436420 | ||||||||
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| Practice Location | |||||||||
| Address1: | 325 9TH AVE | ||||||||
| Address2: | BOX 359803 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981042420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067314240 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 09/23/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD00043267 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084S0012X | MD00043267 | WA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1043375405 | 05 | WA | MEDICAID |