Healthcare Provider Details

I. General information

NPI: 1306333687
Provider Name (Legal Business Name): TIMOTHY G BUSSERT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2018
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E BROADWAY AVE STE 108
JACKSON WY
83001-8640
US

IV. Provider business mailing address

555 E BROADWAY AVE STE 108
JACKSON WY
83001-8640
US

V. Phone/Fax

Practice location:
  • Phone: 307-734-1005
  • Fax:
Mailing address:
  • Phone: 307-734-1005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number315831
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: