Provider Demographics
NPI:1538104179
Name:CUSTER, LEROY EVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LEROY
Middle Name:EVAN
Last Name:CUSTER
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 1:175 LENNON LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2485
Mailing Address - Country:US
Mailing Address - Phone:925-296-7156
Mailing Address - Fax:925-296-7174
Practice Address - Street 1:2450 ASHBY AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2067
Practice Address - Country:US
Practice Address - Phone:925-296-7156
Practice Address - Fax:925-296-7174
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG125592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G125593Medicare PIN
CA00G125596Medicare PIN
CA00G125599Medicare PIN
CA00G125595Medicare PIN
CA300056411Medicare PIN
CA300097019Medicare PIN
CA00G1255910Medicare PIN
CA00G125594Medicare PIN
CA300104427Medicare PIN
CA00G125590Medicare PIN
CA00G125597Medicare PIN
CAA38723Medicare UPIN
CA00G125598Medicare PIN