Provider Demographics
NPI:1558520460
Name:PUSTOVOYTOV, VADIM (DO)
Entity Type:Individual
Prefix:
First Name:VADIM
Middle Name:
Last Name:PUSTOVOYTOV
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:PO BOX 5024
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-5024
Mailing Address - Country:US
Mailing Address - Phone:800-627-4470
Mailing Address - Fax:412-937-5710
Practice Address - Street 1:2510 30TH AVE
Practice Address - Street 2:ANESTHESIOLOGY
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-2448
Practice Address - Country:US
Practice Address - Phone:800-627-4470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247703207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology