Provider Demographics
NPI:1275670291
Name:CUSICK, MICHAEL (MD, MHSA)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:CUSICK
Suffix:
Gender:M
Credentials:MD, MHSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 JEFFERSON PARK AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-3363
Practice Address - Country:US
Practice Address - Phone:434-924-5485
Practice Address - Fax:434-244-9436
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-439428207W00000X, 207WX0107X
VA0101269475207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102474527Medicaid