Provider Demographics
NPI:1922368398
Name:USTYNOSKI, KENNETH R (MD, FACS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:USTYNOSKI
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ONDISH RD
Mailing Address - Street 2:
Mailing Address - City:SHAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18708-9415
Mailing Address - Country:US
Mailing Address - Phone:570-696-4566
Mailing Address - Fax:
Practice Address - Street 1:110 ONDISH RD
Practice Address - Street 2:
Practice Address - City:SHAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:18708-9415
Practice Address - Country:US
Practice Address - Phone:570-696-4566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-20
Last Update Date:2012-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032192E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist