Basic Information
| Provider Information | |||||||||
| NPI: | 1396727012 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUZAYLOV | ||||||||
| FirstName: | VYACHESLAV | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64374 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6672141616 | ||||||||
| FaxNumber: | 4103281674 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 S GREENE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6672141616 | ||||||||
| FaxNumber: | 4103281674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | D0060082 | MD | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 585501200 | 05 | MD | MEDICAID |