Provider Demographics
NPI:1902804636
Name:CUSUMANO, MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:CUSUMANO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 W BAY DR
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-1929
Mailing Address - Country:US
Mailing Address - Phone:727-518-2977
Mailing Address - Fax:727-518-0010
Practice Address - Street 1:2200 W BAY DR
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-1929
Practice Address - Country:US
Practice Address - Phone:727-518-2977
Practice Address - Fax:727-518-0010
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8925208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL71396YMedicare ID - Type Unspecified
FLI15351Medicare UPIN