Provider Demographics
NPI:1881657591
Name:ANTSELIOVICH, PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:ANTSELIOVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PAVEL
Other - Middle Name:
Other - Last Name:ANTSELIOVICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:333 E VIRGINIA AVE STE 119
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1207
Mailing Address - Country:US
Mailing Address - Phone:602-277-5731
Mailing Address - Fax:602-277-5107
Practice Address - Street 1:333 E VIRGINIA AVE STE 119
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1207
Practice Address - Country:US
Practice Address - Phone:602-277-5731
Practice Address - Fax:602-277-5107
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34422208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics