Provider Demographics
NPI:1053392811
Name:BUSBY, MICKY L (MD)
Entity type:Individual
Prefix:DR
First Name:MICKY
Middle Name:L
Last Name:BUSBY
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 1:317 W GAINES ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-3604
Mailing Address - Country:US
Mailing Address - Phone:931-762-9665
Mailing Address - Fax:931-766-0767
Practice Address - Street 1:317 W GAINES ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-3604
Practice Address - Country:US
Practice Address - Phone:931-762-9665
Practice Address - Fax:931-766-0767
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD11256207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3180810Medicaid
TN3180810Medicaid
TNB03928Medicare UPIN