Healthcare Provider Details

I. General information

NPI: 1508560269
Provider Name (Legal Business Name): BORIS YUSHUVAYEV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26224 N TATUM BLVD STE 5
PHOENIX AZ
85050-7500
US

IV. Provider business mailing address

2500 W UTOPIA RD STE 100
PHOENIX AZ
85027-4172
US

V. Phone/Fax

Practice location:
  • Phone: 480-882-7580
  • Fax: 480-563-7442
Mailing address:
  • Phone: 623-683-4462
  • Fax: 623-683-4963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number012642
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: