Provider Demographics
NPI:1235283367
Name:KUSSELUK, ERIC (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:KUSSELUK
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 1:635 MADISON AVE
Mailing Address - Street 2:3RD FLOOR DERMATOLOGY
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-1009
Mailing Address - Country:US
Mailing Address - Phone:212-753-6033
Mailing Address - Fax:212-308-6847
Practice Address - Street 1:635 MADISON AVE
Practice Address - Street 2:3RD FLOOR DERMATOLOGY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1009
Practice Address - Country:US
Practice Address - Phone:212-753-6033
Practice Address - Fax:212-308-6847
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239183207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology