Provider Demographics
NPI:1558567974
Name:BUSSELBERG, PETER DONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:DONALD
Last Name:BUSSELBERG
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:PO BOX 1450 NW 6035
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55485-6035
Mailing Address - Country:US
Mailing Address - Phone:952-542-8553
Mailing Address - Fax:
Practice Address - Street 1:5775 WAYZATA BLVD.
Practice Address - Street 2:SUITE 190
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2627
Practice Address - Country:US
Practice Address - Phone:952-541-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT1891432085R0202X
MN562832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology