Healthcare Provider Details

I. General information

NPI: 1366917627
Provider Name (Legal Business Name): JACQUES EMILE BUSSIERE CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2018
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2453 KENBROOK CT
WALDORF MD
20603-3227
US

IV. Provider business mailing address

PO BOX 221135
CHANTILLY VA
20153-1135
US

V. Phone/Fax

Practice location:
  • Phone: 301-257-6191
  • Fax:
Mailing address:
  • Phone: 703-349-1379
  • Fax: 703-591-0005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: