Healthcare Provider Details

I. General information

NPI: 1275964918
Provider Name (Legal Business Name): ALEKSANDR KOMAROV DPM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2013
Last Update Date: 10/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 N LAKE SHORE DR APT 708
CHICAGO IL
60610-8442
US

IV. Provider business mailing address

1360 N LAKE SHORE DR APT 708
CHICAGO IL
60610-8442
US

V. Phone/Fax

Practice location:
  • Phone: 248-787-3625
  • Fax:
Mailing address:
  • Phone: 248-787-3625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. ALEKSANDR KOMAROV
Title or Position: CEO, SOLE MEMBER
Credential: DPM
Phone: 248-787-9684