Provider Demographics
NPI:1720187289
Name:CUSACK, BARRY JUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:JUSTIN
Last Name:CUSACK
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 1:9550 CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83714-1264
Mailing Address - Country:US
Mailing Address - Phone:208-375-8560
Mailing Address - Fax:
Practice Address - Street 1:500 WEST FORT ST
Practice Address - Street 2:(111)
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4598
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:208-422-1319
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5678207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM5678OtherSTATE MEDICAL LICENCE