Healthcare Provider Details

I. General information

NPI: 1730174756
Provider Name (Legal Business Name): DONALD J KUSHON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COWLES ST FAIRBANKS MEMORIAL HOSPITAL
FAIRBANKS AK
99701-5925
US

IV. Provider business mailing address

1601 CHERRY ST SUITE 11511
PHILA PA
19102-1320
US

V. Phone/Fax

Practice location:
  • Phone: 907-458-5525
  • Fax: 907-458-5514
Mailing address:
  • Phone: 215-255-7822
  • Fax: 215-255-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD042233E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: