Healthcare Provider Details

I. General information

NPI: 1700441334
Provider Name (Legal Business Name): VICTOR BUSHLYAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 04/21/2024
Certification Date: 04/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 HOWARD AVE LOWR LEVEL
NEW HAVEN CT
06519-1369
US

IV. Provider business mailing address

15 YORK ST P.O. BOX 208018
NEW HAVEN CT
06510-3221
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-4085
  • Fax:
Mailing address:
  • Phone: 203-785-6351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number75367
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: