Healthcare Provider Details

I. General information

NPI: 1093767758
Provider Name (Legal Business Name): ANDREW MICHAEL KUSIENSKI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR UNIT MEDDAC
FT CARSON CO
80913-4604
US

IV. Provider business mailing address

8325 MISTY MOON DR
COLORADO SPRINGS CO
80924-4482
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-2273
  • Fax: 719-524-2258
Mailing address:
  • Phone: 719-216-2595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberDR006374
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: