Provider Demographics
NPI:1881690956
Name:IE, DARMAKUSUMA (MD)
Entity Type:Individual
Prefix:
First Name:DARMAKUSUMA
Middle Name:
Last Name:IE
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 1:4 PRINCESS RD
Mailing Address - Street 2:STE 101
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2322
Mailing Address - Country:US
Mailing Address - Phone:609-896-1414
Mailing Address - Fax:609-896-2982
Practice Address - Street 1:4 PRINCESS RD
Practice Address - Street 2:STE 101
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2322
Practice Address - Country:US
Practice Address - Phone:609-896-1414
Practice Address - Fax:609-896-2982
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05957000207W00000X
PAMD049688-L207W00000X
CAG073259207W00000X
FL61304207W00000X
MDD43059207W00000X
NY178644207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ091801AW0Medicare ID - Type Unspecified
PA091775GQPMedicare ID - Type Unspecified
F37646Medicare UPIN