Healthcare Provider Details

I. General information

NPI: 1932255395
Provider Name (Legal Business Name): ALIAKSEI PUSTAVOITAU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 01/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST MEYER 297-A
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

PO BOX 64382
BALTIMORE MD
21264-4382
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-9080
  • Fax:
Mailing address:
  • Phone: 410-550-8432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number4301079531
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberD65752
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: