Provider Demographics
NPI:1477614196
Name:KANYUK-STOUPNITSKA, ROSTISLAVA (MD)
Entity Type:Individual
Prefix:
First Name:ROSTISLAVA
Middle Name:
Last Name:KANYUK-STOUPNITSKA
Suffix:
Gender:F
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 9132
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446
Mailing Address - Country:US
Mailing Address - Phone:978-296-2302
Mailing Address - Fax:978-296-2304
Practice Address - Street 1:138 HAVERHILL STREET
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810
Practice Address - Country:US
Practice Address - Phone:978-296-2302
Practice Address - Fax:978-296-2304
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38662207L00000X
MA233627207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
129960OtherFALLON
1477614196OtherUHC
MA2142171Medicaid
41844OtherNHP
1477614196OtherBMC
NH30207632Medicaid
J42642OtherBCBS
8961939OtherCIGNA
AA97507OtherHPHC
459069OtherTUFTS
95855401OtherNETWORK HEALTH
41844OtherNHP
1477614196OtherBMC
459069OtherTUFTS