Provider Demographics
NPI:1164404901
Name:FUSSELL, KEVIN M (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:FUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 SANTA FE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-5157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:326 SANTA FE DR STE 100
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5157
Practice Address - Country:US
Practice Address - Phone:760-230-8994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC172323207RC0200X, 207RP1001X
GA067298207RC0200X
VA0101269338207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003121258AMedicaid
GA003121258DMedicaid
GA003121258AMedicaid
GA202I939707Medicare PIN