Provider Demographics
NPI:1306409438
Name:BUSSELL, CHARLES STANTON (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:STANTON
Last Name:BUSSELL
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:PO BOX 23189
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76702-3189
Mailing Address - Country:US
Mailing Address - Phone:254-537-0911
Mailing Address - Fax:254-537-0313
Practice Address - Street 1:364 RICHLAND WEST CIR STE A
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7919
Practice Address - Country:US
Practice Address - Phone:254-537-0911
Practice Address - Fax:254-537-0313
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT1025207RG0100X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program