Provider Demographics
NPI:1396185161
Name:KUSNEZOV, NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:KUSNEZOV
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 1:9834 GENESEE AVE STE 228
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1215
Mailing Address - Country:US
Mailing Address - Phone:858-455-9942
Mailing Address - Fax:858-455-6473
Practice Address - Street 1:9834 GENESEE AVE STE 228
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1215
Practice Address - Country:US
Practice Address - Phone:858-455-9942
Practice Address - Fax:858-455-6473
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036147531207X00000X
KY51891207X00000X
CAA155908207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery