Healthcare Provider Details

I. General information

NPI: 1053686493
Provider Name (Legal Business Name): MELANIE CUSTER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 VETERANS AVE UNIT 106
WEST BEND WI
53090-2559
US

IV. Provider business mailing address

103 FINANCIAL PL SUITE 100
ELIZABETHTOWN KY
42701-4470
US

V. Phone/Fax

Practice location:
  • Phone: 262-353-4460
  • Fax: 262-353-4461
Mailing address:
  • Phone: 270-769-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number70643-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: