Provider Demographics
NPI:1093163081
Name:KUST, MICAH
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:KUST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2544 E SUNRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3228
Mailing Address - Country:US
Mailing Address - Phone:954-253-0853
Mailing Address - Fax:954-416-3625
Practice Address - Street 1:2544 E SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3228
Practice Address - Country:US
Practice Address - Phone:954-253-0853
Practice Address - Fax:954-416-3625
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13416225100000X
FL31513225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist