Basic Information
| Provider Information | |||||||||
| NPI: | 1861758385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BELOUSOV | ||||||||
| FirstName: | YEKATERINA | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 S PINE ISLAND RD | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333243920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549657331 | ||||||||
| FaxNumber: | 9549657339 | ||||||||
| Practice Location | |||||||||
| Address1: | 21097 NE 27TH CT | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331801204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056829877 | ||||||||
| FaxNumber: | 3056821602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2012 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | OS13264 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 014888100 | 05 | FL | MEDICAID |