Healthcare Provider Details

I. General information

NPI: 1073019717
Provider Name (Legal Business Name): ALEXANDER VARTANOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 COTTMAN AVE
PHILADELPHIA PA
19111-2434
US

IV. Provider business mailing address

131 COVENTRY ST FL 2
HARTFORD CT
06112-1548
US

V. Phone/Fax

Practice location:
  • Phone: 215-728-2570
  • Fax:
Mailing address:
  • Phone: 860-714-3690
  • Fax: 860-714-8541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMD485461
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: