Provider Demographics
NPI:1205944089
Name:CUSANO, ANTHONY J II (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:CUSANO
Suffix:II
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 1:140 GRANDVIEW AVENUE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708
Mailing Address - Country:US
Mailing Address - Phone:203-597-9733
Mailing Address - Fax:203-597-9732
Practice Address - Street 1:140 GRANDVIEW AVENUE
Practice Address - Street 2:SUITE L02
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708
Practice Address - Country:US
Practice Address - Phone:203-757-5798
Practice Address - Fax:203-757-5161
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT030022207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001300227Medicaid
A61752Medicare UPIN
CT001300227Medicaid