Provider Demographics
NPI:1508802919
Name:BUSLON, BENNY (MD)
Entity Type:Individual
Prefix:
First Name:BENNY
Middle Name:
Last Name:BUSLON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 PARKWAY AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-9348
Mailing Address - Country:US
Mailing Address - Phone:219-309-8149
Mailing Address - Fax:
Practice Address - Street 1:1004 PARKWAY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-9348
Practice Address - Country:US
Practice Address - Phone:219-309-8149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033352207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100209290Medicaid
IN145420Medicare PIN