Provider Demographics
NPI:1114192556
Name:GUSAKOV, OLEG (MD)
Entity Type:Individual
Prefix:
First Name:OLEG
Middle Name:
Last Name:GUSAKOV
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:PO BOX 829642
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-9642
Mailing Address - Country:US
Mailing Address - Phone:866-470-6626
Mailing Address - Fax:
Practice Address - Street 1:1 ROBERT WOOD JOHNSON PL
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1928
Practice Address - Country:US
Practice Address - Phone:732-828-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA239565207L00000X
MA229754207L00000X
NJ25MA10467000207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110082461AMedicaid
MA001127201Medicare PIN