Provider Demographics
NPI:1972092518
Name:CUSMANO, KATELYN ROSE (MD)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ROSE
Last Name:CUSMANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATELYN
Other - Middle Name:
Other - Last Name:CUSMANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1 LONG WHARF DR STE 105
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5991
Mailing Address - Country:US
Mailing Address - Phone:203-865-3737
Mailing Address - Fax:
Practice Address - Street 1:1 LONG WHARF DR STE 105
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5991
Practice Address - Country:US
Practice Address - Phone:203-865-3737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT68062208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty