Provider Demographics
NPI:1730108291
Name:AVSHALUMOV, STANISLAV (DO)
Entity Type:Individual
Prefix:DR
First Name:STANISLAV
Middle Name:
Last Name:AVSHALUMOV
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 1:141B E MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580
Mailing Address - Country:US
Mailing Address - Phone:718-738-2220
Mailing Address - Fax:
Practice Address - Street 1:141B E MERRICK RD
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580
Practice Address - Country:US
Practice Address - Phone:718-738-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233630207X00000X
MO2008004480207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA4000014691Medicare PIN