Provider Demographics
NPI:1093277220
Name:RAI, KUSUM (MD)
Entity Type:Individual
Prefix:
First Name:KUSUM
Middle Name:
Last Name:RAI
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 1:7259 S BINGHAM JUNCTION BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-4860
Mailing Address - Country:US
Mailing Address - Phone:800-453-3030
Mailing Address - Fax:
Practice Address - Street 1:7259 S BINGHAM JUNCTION BLVD
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-4860
Practice Address - Country:US
Practice Address - Phone:800-453-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH57.247990207Q00000X
ORMD210992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program