Provider Demographics
NPI:1992149835
Name:POLIASHENKO, STANISLAV M (MD)
Entity type:Individual
Prefix:
First Name:STANISLAV
Middle Name:M
Last Name:POLIASHENKO
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 1:10800 E GEDDES AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112-3895
Mailing Address - Country:US
Mailing Address - Phone:303-761-9190
Mailing Address - Fax:720-874-4462
Practice Address - Street 1:10800 E GEDDES AVE STE 300
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80112-3895
Practice Address - Country:US
Practice Address - Phone:303-761-9190
Practice Address - Fax:720-874-4462
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2024-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6240207R00000X
CO614932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO832218OtherMEDICARE
NENA1214147OtherMEDICARE
CO832216OtherMEDICARE
CO832219OtherMEDICARE
CO9000170766Medicaid
KS111257135OtherMEDICARE
KSKA3249126OtherMEDICARE
NENA2517124OtherMEDICARE
NENA1215148OtherMEDICARE