Provider Demographics
NPI:1295738417
Name:KUSTRUP, WILLIAM J (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:KUSTRUP
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 1:123 FRANKLIN CORNER RD
Mailing Address - Street 2:STE 207
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2526
Mailing Address - Country:US
Mailing Address - Phone:609-896-9448
Mailing Address - Fax:609-896-7052
Practice Address - Street 1:123 FRANKLIN CORNER RD
Practice Address - Street 2:STE 207
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2526
Practice Address - Country:US
Practice Address - Phone:609-896-9448
Practice Address - Fax:609-896-7052
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2013-10-31
Deactivation Date:2008-03-10
Deactivation Code:
Reactivation Date:2013-10-31
Provider Licenses
StateLicense IDTaxonomies
NJ25MA018330207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8626006Medicaid
NJC56062Medicare UPIN
NJ8626006Medicaid