Provider Demographics
NPI:1942299938
Name:KUSHNET, MARVIN (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:KUSHNET
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:PO BOX 946
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-0946
Mailing Address - Country:US
Mailing Address - Phone:518-783-3167
Mailing Address - Fax:518-786-1293
Practice Address - Street 1:600 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12204-1004
Practice Address - Country:US
Practice Address - Phone:518-471-3283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1379802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B80791Medicare UPIN
CC2614Medicare ID - Type Unspecified