Provider Demographics
NPI:1841842523
Name:CUSCO, JORGE LUIS (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:CUSCO
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 1:52 UNDERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1110
Mailing Address - Country:US
Mailing Address - Phone:321-841-3581
Mailing Address - Fax:321-841-4085
Practice Address - Street 1:52 UNDERWOOD ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1110
Practice Address - Country:US
Practice Address - Phone:321-841-3581
Practice Address - Fax:321-841-4085
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME171100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL125199400Medicaid