Provider Demographics
NPI:1275506016
Name:CUSHMAN, KENNETH D (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:D
Last Name:CUSHMAN
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:520 EAST DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702
Practice Address - Country:US
Practice Address - Phone:903-593-1721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9483207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129526304Medicaid
TXCU083Y750OtherBCBS
TX4540308OtherAETNA
TX080078392OtherMEDICARE RAILROAD
TX123043OtherCHIPS
TX752616977048OtherTRICARE CHAMPUS
TX123043OtherCHIPS
TX752616977048OtherTRICARE CHAMPUS
TX129526304Medicaid