Healthcare Provider Details

I. General information

NPI: 1619240629
Provider Name (Legal Business Name): ILIA NIKOLAEVICH BUHTOIAROV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE # R3-118
CLEVELAND OH
44195-6007
US

IV. Provider business mailing address

9500 EUCLID AVE # R3-118
CLEVELAND OH
44195-1056
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-3736
  • Fax:
Mailing address:
  • Phone: 216-444-3736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number35.126118
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: