Provider Demographics
NPI:1053686493
Name:CUSTER, MELANIE (MD)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:CUSTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 FINANCIAL PL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-4470
Mailing Address - Country:US
Mailing Address - Phone:270-769-0110
Mailing Address - Fax:
Practice Address - Street 1:611 VETERANS AVE UNIT 106
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53090-2559
Practice Address - Country:US
Practice Address - Phone:262-353-4460
Practice Address - Fax:262-353-4461
Is Sole Proprietor?:No
Enumeration Date:2012-03-19
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI70643-20208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1053686493Medicaid