Provider Demographics
NPI:1326156878
Name:KUSSEROW, KURT S (MD)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:S
Last Name:KUSSEROW
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:P.O. BOX 12020
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-2020
Mailing Address - Country:US
Mailing Address - Phone:888-556-5613
Mailing Address - Fax:
Practice Address - Street 1:2000 SUTTER PLACE
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-6201
Practice Address - Country:US
Practice Address - Phone:530-756-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91540207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A915400Medicaid
CAAR585ZMedicare PIN
CA00A915400Medicaid
CA00A915400Medicare PIN