Healthcare Provider Details

I. General information

NPI: 1265458160
Provider Name (Legal Business Name): RODNEY B. KUSUMI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 N 13TH ST
LAFAYETTE IN
47904-2011
US

IV. Provider business mailing address

1013 N 13TH ST
LAFAYETTE IN
47904-2011
US

V. Phone/Fax

Practice location:
  • Phone: 765-428-8888
  • Fax: 765-428-8889
Mailing address:
  • Phone: 765-428-8888
  • Fax: 765-428-8889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number01057576A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: