Provider Demographics
NPI:1497109219
Name:FAYBUSOVICH, PAUL (DO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:FAYBUSOVICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CENTRACARE CIR STE 1325
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-654-3650
Mailing Address - Fax:320-654-3681
Practice Address - Street 1:1900 CENTRACARE CIR STE 1325
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-654-3650
Practice Address - Fax:320-654-3681
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT019251207K00000X
PAOS020058207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine