Provider Demographics
NPI:1457311649
Name:KAPUSTIN, ANDREW J (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:J
Last Name:KAPUSTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 221249
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28222-1249
Mailing Address - Country:US
Mailing Address - Phone:704-332-1291
Mailing Address - Fax:704-332-5206
Practice Address - Street 1:3623 LATROBE DR
Practice Address - Street 2:STE 216
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211
Practice Address - Country:US
Practice Address - Phone:704-332-1291
Practice Address - Fax:704-332-5206
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005005532085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN53005Medicaid
NC5902121Medicaid
2041784Medicare ID - Type Unspecified
NC5902121Medicaid