Provider Demographics
NPI:1184485104
Name:KUSAKAVITCH, MELANIE (DO)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:KUSAKAVITCH
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 1:11 OSBORNE DR
Mailing Address - Street 2:
Mailing Address - City:PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18640-3752
Mailing Address - Country:US
Mailing Address - Phone:570-760-6896
Mailing Address - Fax:
Practice Address - Street 1:301 FISHER ST RM 5A127
Practice Address - Street 2:
Practice Address - City:KEESLER AFB
Practice Address - State:MS
Practice Address - Zip Code:39534-2508
Practice Address - Country:US
Practice Address - Phone:228-376-5571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program