Individual
JOHN P CUSACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3554 PROMENADE PKWY, SUITE F, LAFAYETTE, IN 47909-8418
(765) 477-2200
(765) 477-0277
Mailing address
PO BOX 4699, LAFAYETTE, IN 47903-4699
(765) 449-2732
(765) 449-1196
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01042414A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000348750
ANTHEM PROVIDER NUMBER
IN
05
—
100461530
—
IN
Enumeration date
03/14/2006
Last updated
03/22/2021
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