Provider Demographics
NPI:1740669845
Name:FUSTOK, HUSSAM A (MD)
Entity type:Individual
Prefix:DR
First Name:HUSSAM
Middle Name:A
Last Name:FUSTOK
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 1:1968 FISHINGER RD
Mailing Address - Street 2:
Mailing Address - City:UPPER ARLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43221-1372
Mailing Address - Country:US
Mailing Address - Phone:281-701-2926
Mailing Address - Fax:
Practice Address - Street 1:272 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-9031
Practice Address - Country:US
Practice Address - Phone:740-779-8572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022045087207R00000X, 208M00000X
OH35.134179207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1740669845Medicaid
OH0299838Medicaid