Basic Information
| Provider Information | |||||||||
| NPI: | 1659473858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUSHNAR | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 NW 167TH ST STE 120 | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162944440 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5264 LEE RD | ||||||||
| Address2: | |||||||||
| City: | MAPLE HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441371232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162944440 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 04/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34006625K | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 743136652 | 01 | OH | COMMERCIAL CARRIERS | OTHER | 2074946 | 05 | OH | MEDICAID | 743136652028 | 05 | OH | MEDICAID | 384812 | 01 | OH | ANTHEM PROVIDER NUMBER | OTHER | 5342673 | 01 | OH | AETNA PROVIDER NUMBER | OTHER |