Provider Demographics
NPI:1033201033
Name:LUSK, KEVIN R (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:LUSK
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:PO BOX 1028
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47547-1028
Mailing Address - Country:US
Mailing Address - Phone:812-996-0410
Mailing Address - Fax:812-996-8497
Practice Address - Street 1:115 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FERDINAND
Practice Address - State:IN
Practice Address - Zip Code:47532-9534
Practice Address - Country:US
Practice Address - Phone:812-367-1906
Practice Address - Fax:812-367-2487
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048988A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200441670BMedicaid
IN192680CMedicare ID - Type UnspecifiedMEDICARE
IN200441670BMedicaid