Basic Information
| Provider Information | |||||||||
| NPI: | 1720175466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUSTASZ | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD STE A109B | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178842976 | ||||||||
| FaxNumber: | 5174323928 | ||||||||
| Practice Location | |||||||||
| Address1: | 463 EAST CIRCLE DRIVE | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488241037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178846546 | ||||||||
| FaxNumber: | 5174329460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101013047 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 114424862 | 05 | MI | MEDICAID | 383218134 | 01 | MI | TRICARE | OTHER | 1015065 | 01 | MI | MCLAREN | OTHER | 1720175466 | 05 | MI | MEDICAID | 02017 | 01 | MI | PRIORITY HEALTH PAY TO # | OTHER | 4424862 | 01 | MI | MOLINA | OTHER | 200000002259 | 01 | MI | PHPMM | OTHER | 700C460070 | 01 | MI | BCBS GROUP NUMBER | OTHER |