Provider Demographics
NPI:1801292255
Name:BUSTER DERMATOLOGY PC
Entity type:Organization
Organization Name:BUSTER DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KESHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-749-5714
Mailing Address - Street 1:3915 E 51ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-3605
Mailing Address - Country:US
Mailing Address - Phone:918-749-5714
Mailing Address - Fax:918-749-5826
Practice Address - Street 1:3915 E 51ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3605
Practice Address - Country:US
Practice Address - Phone:918-749-5714
Practice Address - Fax:918-749-5826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-12
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty