Provider Demographics
NPI:1386625077
Name:KUSTAN, JOHN A (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:KUSTAN
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 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:3073 WHITE MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:NORTH CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03860-7101
Practice Address - Country:US
Practice Address - Phone:603-356-5461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME189192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA300134160OtherRXR MEDICARE
MA3033384Medicaid
AZ92433301Medicaid
AKMD298MAMedicaid
CAXPY199908Medicaid
MAJ07321OtherBCBS
WY118342700Medicaid
CAXPY199908OtherMEDICAID CA NORTH
OH341958451013OtherMEDICAL MUTUAL
34195845144193OtherTRICARE WEST
A66586Medicare UPIN
MAJ07321Medicare PIN
PA1017414570002Medicaid
OH2343315Medicaid
ID806481600Medicaid