Healthcare Provider Details

I. General information

NPI: 1295599447
Provider Name (Legal Business Name): DR. ELLEN LAURA ROSE CUSANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9333 GENESEE AVE STE 310
SAN DIEGO CA
92121-2103
US

IV. Provider business mailing address

200 W ARBOR DR # 0829
SAN DIEGO CA
92103-1911
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-6028
  • Fax: 858-249-2519
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberA194088
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: