Provider Demographics
NPI:1639283138
Name:BUSSIAN, TODD G (OD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:G
Last Name:BUSSIAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6777
Mailing Address - Country:US
Mailing Address - Phone:815-235-3466
Mailing Address - Fax:815-235-1712
Practice Address - Street 1:980 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6777
Practice Address - Country:US
Practice Address - Phone:815-235-3466
Practice Address - Fax:815-235-1712
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46-7729152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL46-7729Medicaid
ILP16009Medicare ID - Type Unspecified
ILT38395Medicare UPIN
IL0203850001Medicare NSC