Provider Demographics
NPI:1659368207
Name:BELYAEV, STANISLAV V (MD)
Entity Type:Individual
Prefix:
First Name:STANISLAV
Middle Name:V
Last Name:BELYAEV
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 1:603 W COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5211
Mailing Address - Country:US
Mailing Address - Phone:575-624-5624
Mailing Address - Fax:575-622-4279
Practice Address - Street 1:603 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5211
Practice Address - Country:US
Practice Address - Phone:575-624-5624
Practice Address - Fax:575-622-4279
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2003-0691207R00000X
NMMD2003-0691207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM324241YPPROtherMEDICARE PTAN
NM16500075Medicaid
NM780148OtherMEDICARE PTAN / ROSWELL CLINIC CORP