Provider Demographics
NPI:1194875872
Name:CUSTURA, MIRCEA V (MD)
Entity type:Individual
Prefix:
First Name:MIRCEA
Middle Name:V
Last Name:CUSTURA
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 1:600 W 246TH ST
Mailing Address - Street 2:#616
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-3611
Mailing Address - Country:US
Mailing Address - Phone:718-884-3061
Mailing Address - Fax:
Practice Address - Street 1:600 E 233RD ST
Practice Address - Street 2:OLMMC DEPARTMENT OF PSYCHIATRY
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-2604
Practice Address - Country:US
Practice Address - Phone:718-920-9826
Practice Address - Fax:718-920-9217
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1871782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01405178Medicaid
NY14G852Medicare ID - Type Unspecified
NY01405178Medicaid