Provider Demographics
NPI:1679732747
Name:BORISSOV, MIHAIL VALERIEV (MD)
Entity Type:Individual
Prefix:DR
First Name:MIHAIL
Middle Name:VALERIEV
Last Name:BORISSOV
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 1:111 SETTLERS TRACE BLVD
Mailing Address - Street 2:APARTMENT 1404
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6083
Mailing Address - Country:US
Mailing Address - Phone:786-218-7989
Mailing Address - Fax:
Practice Address - Street 1:1214 COOLIDGE BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2621
Practice Address - Country:US
Practice Address - Phone:337-289-7991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.204610208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1082961Medicaid