Provider Demographics
NPI:1073899407
Name:GOLUBOV, VYACHESLAV B (AA)
Entity Type:Individual
Prefix:
First Name:VYACHESLAV
Middle Name:B
Last Name:GOLUBOV
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:SLAVA
Other - Middle Name:
Other - Last Name:GOLUBOV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AA
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:12222 MERIT DR STE 600
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-3294
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1235367H00000X
TX367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant