Basic Information
| Provider Information | |||||||||
| NPI: | 1033110945 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUSUNIS | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1770 N ORANGE GROVE AVE | ||||||||
| Address2: | SUTIE 101 | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094699494 | ||||||||
| FaxNumber: | 9096207285 | ||||||||
| Practice Location | |||||||||
| Address1: | 1770 N ORANGE GROVE AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094699494 | ||||||||
| FaxNumber: | 9094692120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G59736 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1033110945 | 05 | CA | MEDICAID | AK2329022 | 01 | DEA # | OTHER |