Provider Demographics
NPI:1285612036
Name:CUSUMANO, MICHAEL ANTHONY (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:CUSUMANO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 E DAVIS BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3514
Mailing Address - Country:US
Mailing Address - Phone:813-300-7839
Mailing Address - Fax:813-425-9342
Practice Address - Street 1:178 E DAVIS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3514
Practice Address - Country:US
Practice Address - Phone:813-300-7839
Practice Address - Fax:813-425-9342
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2017-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2471152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620343400Medicaid
FL14263Medicare UPIN
FL620343400Medicaid
FL20251TMedicare PIN
FL20251UMedicare PIN