Provider Demographics
NPI:1396727012
Name:FUZAYLOV, VYACHESLAV (MD)
Entity type:Individual
Prefix:
First Name:VYACHESLAV
Middle Name:
Last Name:FUZAYLOV
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:PO BOX 64374
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4374
Mailing Address - Country:US
Mailing Address - Phone:667-214-1616
Mailing Address - Fax:410-328-1674
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:667-214-1616
Practice Address - Fax:410-328-1674
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0060082207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD585501200Medicaid
MD234HMedicare PIN
MDH91290Medicare UPIN
MD596PMedicare PIN
MD585501200Medicaid