Provider Demographics
NPI:1003991100
Name:KALUSTIAN, MICHAEL V (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:V
Last Name:KALUSTIAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 6TH ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-4610
Mailing Address - Country:US
Mailing Address - Phone:203-357-7181
Mailing Address - Fax:203-357-0632
Practice Address - Street 1:30 6TH ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-4610
Practice Address - Country:US
Practice Address - Phone:203-357-7181
Practice Address - Fax:203-357-0632
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002585152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004223020Medicaid
CT410001052Medicare ID - Type Unspecified
CTD400065158Medicare PIN
CT004223020Medicaid