Provider Demographics
NPI:1093172413
Name:BUKASSA, JOSEPH
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:BUKASSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-3855
Mailing Address - Country:US
Mailing Address - Phone:972-803-7272
Mailing Address - Fax:972-221-9305
Practice Address - Street 1:207 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3855
Practice Address - Country:US
Practice Address - Phone:972-803-7272
Practice Address - Fax:972-221-9305
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTRANSPORTATIONMedicaid