Healthcare Provider Details

I. General information

NPI: 1760489504
Provider Name (Legal Business Name): LARRY DEAN BUCSHON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 ST MARYS DR SUITE 300
EVANSVILLE IN
47714-8005
US

IV. Provider business mailing address

901 ST MARYS DR SUITE 300
EVANSVILLE IN
47714-8005
US

V. Phone/Fax

Practice location:
  • Phone: 812-473-2642
  • Fax: 812-474-4458
Mailing address:
  • Phone: 812-473-2642
  • Fax: 812-474-4458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number01048423A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: