1477309573 NPI number — DR. EUGENE ALEXANDER KRUSTEV M.D.

Table of content: DR. EUGENE ALEXANDER KRUSTEV M.D. (NPI 1477309573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477309573 NPI number — DR. EUGENE ALEXANDER KRUSTEV M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRUSTEV
Provider First Name:
EUGENE
Provider Middle Name:
ALEXANDER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477309573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105-2422 ERLTON ST SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALGARY
Provider Business Mailing Address State Name:
AB
Provider Business Mailing Address Postal Code:
T253B6
Provider Business Mailing Address Country Code:
CA
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4940 EASTERN AVE
Provider Second Line Business Practice Location Address:
MYOSITIS CENTRE
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
506-466-8378
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/29/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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