Healthcare Provider Details

I. General information

NPI: 1962407908
Provider Name (Legal Business Name): BRIAN ALEX KUVSHINIKOV DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 SOUTHMOOR CIR NE
DAYTON OH
45429-2451
US

IV. Provider business mailing address

15 SOUTHMOOR CIR NE
DAYTON OH
45429-2451
US

V. Phone/Fax

Practice location:
  • Phone: 937-293-6896
  • Fax: 937-293-9150
Mailing address:
  • Phone: 937-293-6896
  • Fax: 937-293-9150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36-003316
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: