Healthcare Provider Details

I. General information

NPI: 1881657591
Provider Name (Legal Business Name): PAUL ANTSELIOVICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: PAVEL ANTSELIOVICH MD

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E VIRGINIA AVE STE 119
PHOENIX AZ
85004-1207
US

IV. Provider business mailing address

333 E VIRGINIA AVE STE 119
PHOENIX AZ
85004-1207
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-5731
  • Fax: 602-277-5107
Mailing address:
  • Phone: 602-277-5731
  • Fax: 602-277-5107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34422
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: