Provider Demographics
NPI:1376511881
Name:KEVIN T CUSTIS M D P C
Entity type:Organization
Organization Name:KEVIN T CUSTIS M D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:TYRONE
Authorized Official - Last Name:CUSTIS
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:718-363-6675
Mailing Address - Street 1:63 MEADOW LARK LN
Mailing Address - Street 2:
Mailing Address - City:BELLE MEAD
Mailing Address - State:NJ
Mailing Address - Zip Code:08502-4929
Mailing Address - Country:US
Mailing Address - Phone:908-431-7707
Mailing Address - Fax:908-431-9329
Practice Address - Street 1:887 E NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1309
Practice Address - Country:US
Practice Address - Phone:718-778-0069
Practice Address - Fax:718-778-0035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7505055OtherAETNA US HEALTHCARE
NY40 V182OtherEMPIRE BLUE CROSS BLUE SHIELD
NY6016214OtherGHI
NY01976654Medicaid
NY40V183OtherEMPIRE BLUE CROSS BLUE SHIELD
NYP2215900OtherOXFORDN HEALTH PLANS
NY211807OtherHIP