Provider Demographics
NPI:1831292614
Name:SHUSTERMAN, LARRY (DO)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:SHUSTERMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S 28TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-1202
Mailing Address - Country:US
Mailing Address - Phone:215-334-1166
Mailing Address - Fax:215-336-1776
Practice Address - Street 1:1600 S 28TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-1202
Practice Address - Country:US
Practice Address - Phone:215-334-1166
Practice Address - Fax:215-336-1776
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-006113-L207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100326OtherKEYSTONE MERCY HEALTH PLA
PA0080977002OtherKEYSTONE HEALTH PLAN EAST
PA110127288OtherPALMETTO GBA
PA98583OtherUS HEALTHCARE
PA4348882OtherAETNA
PA0011417470005Medicaid
PA0114174702OtherAMERICHOICE
PA6724OtherELDERHEALTH
PA4348882OtherAETNA
PA0011417470005Medicaid