Provider Demographics
NPI:1184730186
Name:BUSSONE, JUSTIN ADAM (DO)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ADAM
Last Name:BUSSONE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2652
Mailing Address - Country:US
Mailing Address - Phone:207-373-6000
Mailing Address - Fax:
Practice Address - Street 1:123 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2652
Practice Address - Country:US
Practice Address - Phone:207-373-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO2129207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRT- 1553OtherLICENSE NUMBER
NH61193OtherBILLING NUMBER
MEDO2129OtherMAINE LICENSE