Healthcare Provider Details

I. General information

NPI: 1942283858
Provider Name (Legal Business Name): JEFFREY D. CUSHMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 SCHATZ POINTE DR
DAYTON OH
45459-3856
US

IV. Provider business mailing address

500 W MAIN ST SUITE 108
BABYLON NY
11702-3027
US

V. Phone/Fax

Practice location:
  • Phone: 937-439-0390
  • Fax: 937-439-7370
Mailing address:
  • Phone: 631-517-8006
  • Fax: 631-517-8007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number34003697C
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: