=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275964918
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALEKSANDR KOMAROV DPM LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2013
-----------------------------------------------------
Last Update Date | 10/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1360 N LAKE SHORE DR APT 708
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-8442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-787-3625
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1360 N LAKE SHORE DR APT 708
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-8442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-787-3625
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO, SOLE MEMBER
-----------------------------------------------------
Name | DR. ALEKSANDR KOMAROV
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 248-787-9684
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------