Provider Demographics
NPI:1134539174
Name:URYASEV, OLEG
Entity type:Individual
Prefix:
First Name:OLEG
Middle Name:
Last Name:URYASEV
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 OLD PECOS TRL
Mailing Address - Street 2:SUITE H
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1640 OLD PECOS TRL
Practice Address - Street 2:SUITE H
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4776
Practice Address - Country:US
Practice Address - Phone:505-992-0233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2017-0084207P00000X
TXV5618207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program