Provider Demographics
NPI:1710257431
Name:KUSIAK, VICTORIA (MD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:KUSIAK
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 1:3320 SHADY BND
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-6291
Mailing Address - Country:US
Mailing Address - Phone:239-693-1655
Mailing Address - Fax:239-693-1656
Practice Address - Street 1:3320 SHADY BND
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-6291
Practice Address - Country:US
Practice Address - Phone:239-693-1655
Practice Address - Fax:239-693-1656
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92209207RC0000X
PAMD018545E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease