Basic Information
| Provider Information | |||||||||
| NPI: | 1750375051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUSUMA | ||||||||
| FirstName: | VITHAL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1009 N MONROE ST | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317011970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298830298 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 902 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310153234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292763100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 021536 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.