Provider Demographics
NPI:1912891029
Name:CUSIMANO, ANTHONY MICHAEL
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MICHAEL
Last Name:CUSIMANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 BROADVIEW AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:UNCASVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06382-1383
Mailing Address - Country:US
Mailing Address - Phone:860-961-0761
Mailing Address - Fax:
Practice Address - Street 1:74 BROADVIEW AVE APT 1
Practice Address - Street 2:
Practice Address - City:UNCASVILLE
Practice Address - State:CT
Practice Address - Zip Code:06382-1383
Practice Address - Country:US
Practice Address - Phone:860-961-0761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-04
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2255A2300X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program