Provider Demographics
NPI:1376859231
Name:MICHAEL C KUSHLAN MD INC
Entity Type:Organization
Organization Name:MICHAEL C KUSHLAN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:KUSHLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-356-0468
Mailing Address - Street 1:2512 SAMARITAN CT STE G
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-4002
Mailing Address - Country:US
Mailing Address - Phone:408-356-0468
Mailing Address - Fax:408-356-4821
Practice Address - Street 1:2512 SAMARITAN CT STE G
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4002
Practice Address - Country:US
Practice Address - Phone:408-356-0468
Practice Address - Fax:408-356-4821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-29
Last Update Date:2012-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFU615AMedicare PIN