Provider Demographics
NPI:1598770430
Name:KUSUMA, SHASHIDHAR (MD)
Entity Type:Individual
Prefix:
First Name:SHASHIDHAR
Middle Name:
Last Name:KUSUMA
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 1:8430 W BROWARD BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2700
Mailing Address - Country:US
Mailing Address - Phone:954-472-8355
Mailing Address - Fax:954-472-8220
Practice Address - Street 1:8430 W BROWARD BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2700
Practice Address - Country:US
Practice Address - Phone:954-472-8355
Practice Address - Fax:954-472-8220
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35088257208200000X
FL107122207YX0007X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2670104Medicaid
OHI55371Medicare UPIN
OH2670104Medicaid