Provider Demographics
NPI:1124195466
Name:KUSTRA BARKSDALE, AMY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:LYNN
Last Name:KUSTRA BARKSDALE
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 1:76 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7649
Mailing Address - Country:US
Mailing Address - Phone:207-795-2800
Mailing Address - Fax:207-795-2808
Practice Address - Street 1:76 HIGH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7649
Practice Address - Country:US
Practice Address - Phone:207-795-2800
Practice Address - Fax:207-795-2808
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME016097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM9920Medicare PIN