Healthcare Provider Details

I. General information

NPI: 1194788117
Provider Name (Legal Business Name): BARRY ALLEN KUSNICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SAINT ELIZABETH WAY STE 110
ST JOHNS FL
32259-1153
US

IV. Provider business mailing address

300 SAINT ELIZABETH WAY STE 110
ST JOHNS FL
32259-1153
US

V. Phone/Fax

Practice location:
  • Phone: 904-691-9100
  • Fax: 904-691-9129
Mailing address:
  • Phone: 904-691-9100
  • Fax: 904-691-9129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberME132096
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME132096
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberME132096
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: