MEDICARE: KEITH KUSUNIS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	G59736	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033110945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH KUSUNIS MD

Provider Business Mailing Address
First Line	:	1770 N ORANGE GROVE AVE
Second Line	:	SUTIE 101
City	:	POMONA
State	:	CA
Zip	:	91767-3027
Country	:	US
Telephone Number	:	909-469-9494
Fax Number	:	909-620-7285

Provider Business Practice Location Address
First Line	:	1770 N ORANGE GROVE AVE STE 101
Second Line	:
City	:	POMONA
State	:	CA
Zip	:	91767-3027
Country	:	US
Telephone Number	:	909-469-9494
Fax Number	:	909-469-2120

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	03/07/2023

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Directions to “ KEITH KUSUNIS MD” Practice Location

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