Provider Demographics
NPI:1720175466
Name:KUSTASZ, RICHARD D (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:D
Last Name:KUSTASZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-2976
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:463 EAST CIRCLE DRIVE
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-1037
Practice Address - Country:US
Practice Address - Phone:517-884-6546
Practice Address - Fax:517-432-9460
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114424862Medicaid
MI383218134OtherTRICARE
MI1015065OtherMCLAREN
MI1720175466Medicaid
MI02017OtherPRIORITY HEALTH PAY TO #
MI4424862OtherMOLINA
MI200000002259OtherPHPMM
MI700C460070OtherBCBS GROUP NUMBER
MI700C460070OtherBCBS GROUP NUMBER
MI114424862Medicaid
MI383218134OtherTRICARE