Provider Demographics
NPI:1578521829
Name:COUSINS, CARISSA SARAH (MD)
Entity Type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:SARAH
Last Name:COUSINS
Suffix:
Gender:F
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:PO BOX 1188
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1188
Mailing Address - Country:US
Mailing Address - Phone:541-812-5111
Mailing Address - Fax:541-812-5127
Practice Address - Street 1:121 SE VIEWMONT AVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-1968
Practice Address - Country:US
Practice Address - Phone:541-766-3546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR156114208000000X
FLME78852208000000X
OH096165208000000X
ORMD156114208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH99790Medicare UPIN