Provider Demographics
NPI:1902193246
Name:AFANASEVICH, VLADISLAV (MD)
Entity Type:Individual
Prefix:
First Name:VLADISLAV
Middle Name:
Last Name:AFANASEVICH
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 1:1438 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1027
Mailing Address - Country:US
Mailing Address - Phone:314-977-4850
Mailing Address - Fax:314-977-4880
Practice Address - Street 1:1438 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1027
Practice Address - Country:US
Practice Address - Phone:314-977-4850
Practice Address - Fax:314-977-4880
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011019832390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program