Provider Demographics
NPI:1083795611
Name:JAY BUSBY MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JAY BUSBY MD A PROFESSIONAL CORPORATION
Other - Org Name:JOSEPH D BUSBY JR MD
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DOCTOR PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BUSBY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:318-435-3777
Mailing Address - Street 1:PO BOX 1575
Mailing Address - Street 2:2106 LOOP ROAD SUITE B
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295
Mailing Address - Country:US
Mailing Address - Phone:318-435-3771
Mailing Address - Fax:318-435-7233
Practice Address - Street 1:2106 LOOP RD
Practice Address - Street 2:SUITE B
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295
Practice Address - Country:US
Practice Address - Phone:318-435-3771
Practice Address - Fax:318-435-7233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1303097Medicaid
LA1303097Medicaid