Healthcare Provider Details

I. General information

NPI: 1134971575
Provider Name (Legal Business Name): ANASTASIYA ANISIMOVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 07/28/2024
Certification Date: 07/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 E EVESHAM RD STE 101A
VOORHEES NJ
08043-1557
US

IV. Provider business mailing address

190 W 54TH ST APT 218
BAYONNE NJ
07002-3298
US

V. Phone/Fax

Practice location:
  • Phone: 856-795-4330
  • Fax: 856-325-3704
Mailing address:
  • Phone: 908-930-0581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: