Provider Demographics
NPI:1598743700
Name:KUSSKE, AMY M (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:KUSSKE
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 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1223 16TH ST STE 3100
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1275
Practice Address - Country:US
Practice Address - Phone:424-259-8791
Practice Address - Fax:424-899-7557
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78872208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G788720OtherMEDI-CAL PPIN #
CA00G788720OtherMEDI-CAL PPIN #
H03453Medicare UPIN
CAWG78872AMedicare PIN