Provider Demographics
NPI:1932151644
Name:BUSSARD, GORDON A (MD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:A
Last Name:BUSSARD
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 1:3501 SILVERSIDE ROAD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-4910
Mailing Address - Country:US
Mailing Address - Phone:302-479-3937
Mailing Address - Fax:302-477-2650
Practice Address - Street 1:3501 SILVERSIDE ROAD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-4910
Practice Address - Country:US
Practice Address - Phone:302-479-3937
Practice Address - Fax:302-477-2650
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10000625207W00000X
DEC1-0000625207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000055401Medicaid
180018339OtherMEDICARE RR
180018339OtherMEDICARE RR
DE0000055401Medicaid
B66479Medicare UPIN