Healthcare Provider Details

I. General information

NPI: 1669477881
Provider Name (Legal Business Name): KELLY R. PUSTER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S NAPPANEE ST
ELKHART IN
46514-2066
US

IV. Provider business mailing address

PO BOX 2968
ELKHART IN
46515-2968
US

V. Phone/Fax

Practice location:
  • Phone: 574-296-3220
  • Fax: 574-296-3322
Mailing address:
  • Phone: 574-296-3220
  • Fax: 574-296-3322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01057142A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: