Provider Demographics
NPI:1730100447
Name:MUSSON, JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:MUSSON
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 1:3821 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1667
Mailing Address - Country:US
Mailing Address - Phone:262-687-8460
Mailing Address - Fax:
Practice Address - Street 1:3821 SPRING ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1667
Practice Address - Country:US
Practice Address - Phone:262-687-8460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30320207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIA77028Medicare UPIN