Provider Demographics
NPI:1104667765
Name:CUSACK, REBECCA L (MD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:L
Last Name:CUSACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 WARRINGTON DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401A JEFFERSON HIGHWAY, ACADEMIC CENTRE, FIRST FLOOR
Practice Address - Street 2:
Practice Address - City:JEFFERSON, NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121
Practice Address - Country:US
Practice Address - Phone:504-842-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA342474390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program