Individual
KEVIN TYRONE CUSTIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
86 E 49TH ST, SUITE A, BROOKLYN, NY 11203-1901
(718) 363-6675
Mailing address
63 MEADOW LARK LN, BELLE MEAD, NJ 08502-4929
(908) 281-7591
(908) 431-9329
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
211807
NY
207Q00000X
Family Medicine Physician
25MA08719200
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01976654
—
NY
Enumeration date
01/16/2006
Last updated
09/26/2012
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