Healthcare Provider Details

I. General information

NPI: 1386625077
Provider Name (Legal Business Name): JOHN A KUSTAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3073 WHITE MOUNTAIN HWY
NORTH CONWAY NH
03860-7101
US

IV. Provider business mailing address

324 GANNETT DR STE 200
SOUTH PORTLAND ME
04106-3266
US

V. Phone/Fax

Practice location:
  • Phone: 603-356-5461
  • Fax:
Mailing address:
  • Phone: 207-482-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME18919
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: