Healthcare Provider Details

I. General information

NPI: 1720881840
Provider Name (Legal Business Name): OLEG BORISIUK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 MEDICAL GROUP UNIT 7095, BOX 185, BLDG. 865
APO AE
09824
US

IV. Provider business mailing address

39 MEDICAL GROUP UNIT 7095, BOX 185, BLDG. 865
APO AE
09824
US

V. Phone/Fax

Practice location:
  • Phone: 314-676-6666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDS045316
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: