Provider Demographics
NPI:1033142914
Name:CUSICK, SERIC (MD)
Entity Type:Individual
Prefix:
First Name:SERIC
Middle Name:
Last Name:CUSICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 S OLA VIS
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4343
Mailing Address - Country:US
Mailing Address - Phone:707-812-2983
Mailing Address - Fax:
Practice Address - Street 1:1713 S OLA VIS
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4343
Practice Address - Country:US
Practice Address - Phone:707-812-2983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94644207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A946440Medicare PIN