Provider Demographics
NPI:1932768678
Name:SUSTACHEK, ANTHONY (PT)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:SUSTACHEK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-570-3590
Mailing Address - Fax:414-570-3599
Practice Address - Street 1:200 E RYAN RD
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-4563
Practice Address - Country:US
Practice Address - Phone:414-570-3590
Practice Address - Fax:414-570-3599
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14725225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100089155Medicaid