Individual
DR. BARRY JUSTIN CUSACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
500 WEST FORT ST, (111), BOISE, ID 83702-4598
(208) 422-1000
(208) 422-1319
Mailing address
9550 CHELAN AVE, GARDEN CITY, ID 83714-1264
(208) 375-8560
Taxonomy
Speciality
Code
Description
License number
State
207RG0300X
Geriatric Medicine (Internal Medicine) Physician
Primary
M5678
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
M5678
STATE MEDICAL LICENCE
ID
Enumeration date
09/21/2006
Last updated
07/08/2007
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