Provider Demographics
NPI:1659369338
Name:MCCUISTON, STEVEN J (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:J
Last Name:MCCUISTON
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 1:4905A LAVISTA RD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4437
Mailing Address - Country:US
Mailing Address - Phone:770-493-4620
Mailing Address - Fax:770-270-5301
Practice Address - Street 1:4905A LAVISTA RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4437
Practice Address - Country:US
Practice Address - Phone:770-493-4620
Practice Address - Fax:770-270-5301
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031788207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE91374Medicare UPIN
GA11BDCCNMedicare ID - Type Unspecified