Provider Demographics
NPI:1194771964
Name:VON KUSTER, LARRY (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:VON KUSTER
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 1:715 S TAFT AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-3200
Mailing Address - Country:US
Mailing Address - Phone:419-332-7321
Mailing Address - Fax:419-334-6693
Practice Address - Street 1:715 S TAFT AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-3200
Practice Address - Country:US
Practice Address - Phone:419-332-7321
Practice Address - Fax:419-334-6693
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35047303207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0529128Medicaid
220016456OtherRAILROAD MEDICARE
220016456Medicare PIN
OHF06362Medicare UPIN
OHVO0863422Medicare ID - Type Unspecified
220016456OtherRAILROAD MEDICARE
OH0863422Medicare PIN