Provider Demographics
NPI:1891724753
Name:KUSON, TIM RUKSA (MD)
Entity Type:Individual
Prefix:DR
First Name:TIM
Middle Name:RUKSA
Last Name:KUSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TERMSAK
Other - Middle Name:
Other - Last Name:KUSONRUKSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4910 VAN NUYS BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1879
Mailing Address - Country:US
Mailing Address - Phone:626-419-6842
Mailing Address - Fax:323-550-1530
Practice Address - Street 1:4910 VAN NUYS BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1879
Practice Address - Country:US
Practice Address - Phone:626-419-6842
Practice Address - Fax:323-550-1530
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40625207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF38038Medicare UPIN