Provider Demographics
NPI:1740285212
Name:RAO, KUSUMA (MD)
Entity type:Individual
Prefix:
First Name:KUSUMA
Middle Name:
Last Name:RAO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 758
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-0020
Mailing Address - Country:US
Mailing Address - Phone:770-227-2727
Mailing Address - Fax:770-227-1276
Practice Address - Street 1:703 S 9TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4820
Practice Address - Country:US
Practice Address - Phone:770-227-2727
Practice Address - Fax:770-227-1276
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0271462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00314245AMedicaid
GA$$$$$$$$$AMedicare PIN
GAD40931Medicare UPIN