Provider Demographics
NPI:1417923160
Name:SHUSHTARI, J KEVIN
Entity type:Individual
Prefix:
First Name:J
Middle Name:KEVIN
Last Name:SHUSHTARI
Suffix:
Gender:M
Credentials:
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 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-4896
Mailing Address - Fax:941-917-6884
Practice Address - Street 1:326 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2740
Practice Address - Country:US
Practice Address - Phone:941-917-4896
Practice Address - Fax:941-917-6884
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121844207R00000X
CT036002207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
3114253OtherAETNA
CT001360023Medicaid
110247602OtherRAILROAD MEDICARE
1221925OtherUNITED
CT010036002CT01OtherBLUE CROSS
2V2738OtherHEALTHNET
P2832183OtherOXFORD
P2832183OtherOXFORD
CT110008658Medicare ID - Type Unspecified