Provider Demographics
NPI:1295599447
Name:CUSANO, ELLEN LAURA ROSE
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:LAURA ROSE
Last Name:CUSANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W ARBOR DR # 0829
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9333 GENESEE AVE STE 310
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2103
Practice Address - Country:US
Practice Address - Phone:858-657-6028
Practice Address - Fax:858-249-2519
Is Sole Proprietor?:No
Enumeration Date:2024-02-08
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA194088207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology