Provider Demographics
NPI:1063863793
Name:CHINNUSAMY, KAUSHAL (O D)
Entity Type:Individual
Prefix:DR
First Name:KAUSHAL
Middle Name:
Last Name:CHINNUSAMY
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4632 SIEBERT RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2863
Mailing Address - Country:US
Mailing Address - Phone:248-525-7509
Mailing Address - Fax:
Practice Address - Street 1:3840 MCKINLEY PKWY
Practice Address - Street 2:S3840 MCKINLEY PLAZA
Practice Address - City:BLASDELL
Practice Address - State:NY
Practice Address - Zip Code:14219-3006
Practice Address - Country:US
Practice Address - Phone:716-822-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008447152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist