Healthcare Provider Details

I. General information

NPI: 1629331830
Provider Name (Legal Business Name): DZMITRY FURSEVICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 W CHARLESTON BLVD STE 504
LAS VEGAS NV
89102-2207
US

IV. Provider business mailing address

PO BOX 7055
RENO NV
89510-7055
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-6437
  • Fax:
Mailing address:
  • Phone: 410-955-4567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number17808
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD83737
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: