Provider Demographics
NPI:1013027374
Name:CUSICK, J DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:J DOUGLAS
Middle Name:
Last Name:CUSICK
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 1:4601 COLLEGE BLVD
Mailing Address - Street 2:SUITE 222
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211
Mailing Address - Country:US
Mailing Address - Phone:913-661-0202
Mailing Address - Fax:913-661-0584
Practice Address - Street 1:4601 COLLEGE BLVD
Practice Address - Street 2:SUITE 222
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211
Practice Address - Country:US
Practice Address - Phone:913-661-0202
Practice Address - Fax:913-661-0584
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0423923208200000X
MOMD100181208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO21177020OtherBLUE SHIELD IND #
KS100458460AMedicaid
MO21177020OtherBLUE SHIELD IND #
KS100458460AMedicaid