Provider Demographics
NPI:1710973532
Name:RUSAKOW, LEE STUART (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:STUART
Last Name:RUSAKOW
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 1:4545 E 9TH AVE
Mailing Address - Street 2:SUITE 504
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-3901
Mailing Address - Country:US
Mailing Address - Phone:303-831-9853
Mailing Address - Fax:303-832-3533
Practice Address - Street 1:4545 E 9TH AVE
Practice Address - Street 2:SUITE 504
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3901
Practice Address - Country:US
Practice Address - Phone:303-831-9853
Practice Address - Fax:303-832-3533
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO295252080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2004704000OtherMEDICAID
KY64034978OtherMEDICAID
OH2252093Medicaid
OHRU4056801Medicare ID - Type Unspecified
OH2252093Medicaid