Provider Demographics
NPI:1659493922
Name:OSIPOV, ROBERT MUSHELOVICH (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MUSHELOVICH
Last Name:OSIPOV
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 1:3810 NORTHDALE BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1871
Mailing Address - Country:US
Mailing Address - Phone:813-961-1331
Mailing Address - Fax:888-812-8191
Practice Address - Street 1:13555 W MCDOWELL RD STE 210
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2628
Practice Address - Country:US
Practice Address - Phone:800-991-6117
Practice Address - Fax:888-812-8191
Is Sole Proprietor?:No
Enumeration Date:2007-04-05
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036131321208600000X
AZ36357208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ612518Medicaid
AZZ145792Medicare PIN
ILIL4760133Medicare PIN