Healthcare Provider Details

I. General information

NPI: 1316569650
Provider Name (Legal Business Name): ANTON VOSKRESENSKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2020
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

PO BOX 61160
CORPUS CHRISTI TX
78466-1160
US

V. Phone/Fax

Practice location:
  • Phone: 877-832-2652
  • Fax: 800-792-9021
Mailing address:
  • Phone: 361-884-2904
  • Fax: 361-371-8376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME169817
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: