Provider Demographics
NPI:1770726127
Name:BUTE GUSAIM, ANATOLI ANDREEVICH
Entity type:Individual
Prefix:
First Name:ANATOLI
Middle Name:ANDREEVICH
Last Name:BUTE GUSAIM
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 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:2855 CRAIN HWY
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-2807
Practice Address - Country:US
Practice Address - Phone:240-427-1926
Practice Address - Fax:240-427-1927
Is Sole Proprietor?:No
Enumeration Date:2009-04-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0074617207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD245639YVZ - 945LMedicare UPIN
MD245639YVZMedicare PIN
MD245639ZDDBMedicare PIN
MD245639ZDDB - 149619Medicare UPIN
DC327850YWV2Medicare PIN