Provider Demographics
NPI:1396162202
Name:LAWRENCE MICHAEL CUSMA, OD
Entity type:Organization
Organization Name:LAWRENCE MICHAEL CUSMA, OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CUSMA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:518-399-6368
Mailing Address - Street 1:9 GLEASON RD
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-5307
Mailing Address - Country:US
Mailing Address - Phone:518-399-6368
Mailing Address - Fax:518-399-6372
Practice Address - Street 1:9 GLEASON RD
Practice Address - Street 2:
Practice Address - City:SCOTIA
Practice Address - State:NY
Practice Address - Zip Code:12302-5307
Practice Address - Country:US
Practice Address - Phone:518-399-6368
Practice Address - Fax:518-399-6372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003340-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10000423OtherCAPITAL DISTRICT PHYSICIANS HEALTH PLAN
NY59127OtherMVP HEALTH PLAN
NY10000423OtherCAPITAL DISTRICT PHYSICIANS HEALTH PLAN