Provider Demographics
NPI:1114000585
Name:KOUZNETSOV, ANDREI (MD)
Entity Type:Individual
Prefix:
First Name:ANDREI
Middle Name:
Last Name:KOUZNETSOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 WASHINGTON ST
Mailing Address - Street 2:NEMC BOX #836
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1526
Mailing Address - Country:US
Mailing Address - Phone:617-636-5000
Mailing Address - Fax:
Practice Address - Street 1:750 WASHINGTON ST
Practice Address - Street 2:NEMC BOX #836
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1526
Practice Address - Country:US
Practice Address - Phone:617-636-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217009207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A38745Medicare ID - Type Unspecified
I34556Medicare UPIN