Provider Demographics
NPI:1821084740
Name:CUSIMANO, JUNGSIL K (MD)
Entity Type:Individual
Prefix:DR
First Name:JUNGSIL
Middle Name:K
Last Name:CUSIMANO
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 1:3608 BALLASTONE DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-8069
Mailing Address - Country:US
Mailing Address - Phone:607-206-2007
Mailing Address - Fax:
Practice Address - Street 1:3608 BALLASTONE DR
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-8069
Practice Address - Country:US
Practice Address - Phone:607-206-2007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218013207R00000X
FLME116857207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02090426Medicaid
FLHK147ZOtherPTAN
FLHK147ZOtherPTAN
NY02090426Medicaid
H25287Medicare UPIN
FLHK147ZOtherPTAN