Provider Demographics
NPI:1528171428
Name:BUSELMEIER, THEODORE JOSEPH (MD)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:JOSEPH
Last Name:BUSELMEIER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3960 COON RAPIDS BLVD NW
Mailing Address - Street 2:SUITE 116
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2569
Mailing Address - Country:US
Mailing Address - Phone:763-427-8113
Mailing Address - Fax:763-427-8131
Practice Address - Street 1:3960 COON RAPIDS BLVD NW
Practice Address - Street 2:SUITE 116
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2569
Practice Address - Country:US
Practice Address - Phone:763-427-8113
Practice Address - Fax:763-427-8131
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN17699207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA96495Medicare UPIN