Provider Demographics
NPI:1174180327
Name:CHUCHULO, ANASTASYA (MD)
Entity type:Individual
Prefix:DR
First Name:ANASTASYA
Middle Name:
Last Name:CHUCHULO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29000 LITTLE MACK AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3018
Mailing Address - Country:US
Mailing Address - Phone:586-343-8717
Mailing Address - Fax:586-343-8773
Practice Address - Street 1:29000 LITTLE MACK AVE STE A
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-3018
Practice Address - Country:US
Practice Address - Phone:586-343-8717
Practice Address - Fax:586-343-8773
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2025-09-23
Deactivation Date:2020-01-13
Deactivation Code:
Reactivation Date:2020-03-03
Provider Licenses
StateLicense IDTaxonomies
MI4301511510208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery