Provider Demographics
NPI:1578533303
Name:KUSUDA, LEO (MD)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:
Last Name:KUSUDA
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 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4574
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-0000
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4574
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD27316208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR161133OtherNBMC GROUP MEDICAID
OR1407812365OtherMEDICARE GROUP NPI NUMBER
ORCB3544OtherRR MEDICARE GROUP NUMBER
OR0577260001OtherDMERC
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
ORP00406434OtherRR PTAN MEDICARE NUMBER
OR218174Medicaid
OR0577260001OtherDMERC
OR0577260001OtherDMERC
ORR137441Medicare PIN