Provider Demographics
NPI:1578679452
Name:CUSTER, JOHN VERNON (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:VERNON
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 1:1 POSTON RD
Mailing Address - Street 2:SUITE 145
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-3424
Mailing Address - Country:US
Mailing Address - Phone:843-556-4157
Mailing Address - Fax:843-763-8747
Practice Address - Street 1:1 POSTON RD
Practice Address - Street 2:SUITE 145
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-3424
Practice Address - Country:US
Practice Address - Phone:843-556-4157
Practice Address - Fax:843-763-8747
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15084174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC150847Medicaid
SC150847Medicaid