Provider Demographics
NPI:1972582336
Name:DUSSIAS, RENATA KULESSA (DO)
Entity Type:Individual
Prefix:DR
First Name:RENATA
Middle Name:KULESSA
Last Name:DUSSIAS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-3109
Mailing Address - Country:US
Mailing Address - Phone:908-864-4200
Mailing Address - Fax:908-864-4201
Practice Address - Street 1:335 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-3109
Practice Address - Country:US
Practice Address - Phone:908-864-4200
Practice Address - Fax:908-864-4201
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB64570207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H06819Medicare UPIN
NJ033121S4CMedicare ID - Type Unspecified