Provider Demographics
NPI:1750649398
Name:KUSTERER, KRISTEN OWEN (MD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:OWEN
Last Name:KUSTERER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:LAVIERS
Other - Last Name:OWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:445 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1077
Mailing Address - Country:US
Mailing Address - Phone:606-783-6805
Mailing Address - Fax:606-783-6869
Practice Address - Street 1:445 CLINIC DR
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1077
Practice Address - Country:US
Practice Address - Phone:606-783-6805
Practice Address - Fax:606-783-6869
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY492472084P0800X, 2084P0804X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100268330Medicaid
KY240610OtherMEDICARE KY
KY49247OtherSTATE MEDICAL LICENSE