Provider Demographics
NPI:1861854861
Name:FAKTOROVICH, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FAKTOROVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 W RUE DE LA BANQUE APT L
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8000 E MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-4766
Practice Address - Country:US
Practice Address - Phone:303-785-4700
Practice Address - Fax:303-336-8350
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODR.0063520207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program