Healthcare Provider Details

I. General information

NPI: 1780616383
Provider Name (Legal Business Name): CAROL LIISA KUUSISTO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 5TH AVE # 89 SUITE 604
NEW YORK NY
10003-3020
US

IV. Provider business mailing address

41 5TH AVE APT. 2A
NEW YORK NY
10003-4319
US

V. Phone/Fax

Practice location:
  • Phone: 212-675-9343
  • Fax: 212-627-3770
Mailing address:
  • Phone: 212-533-6986
  • Fax: 212-627-3770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number232095
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: