Provider Demographics
NPI:1124047261
Name:BUYANOV, DMITRIY (MD)
Entity type:Individual
Prefix:
First Name:DMITRIY
Middle Name:
Last Name:BUYANOV
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 1:2425 BABCOCK RD
Mailing Address - Street 2:STE 108
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4898
Mailing Address - Country:US
Mailing Address - Phone:210-616-9400
Mailing Address - Fax:210-616-9402
Practice Address - Street 1:2425 BABCOCK RD.
Practice Address - Street 2:STE 108
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4899
Practice Address - Country:US
Practice Address - Phone:210-616-9400
Practice Address - Fax:210-616-9402
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7996207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166300703Medicaid
TX8D1704Medicare ID - Type Unspecified
TXI04170Medicare UPIN