MEDICARE: DR. OLEKSANDR SELEVERSTOV MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	MD61002582	WA

General Provider Information

NPI Number	:	1770841421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OLEKSANDR SELEVERSTOV MD

Provider Business Mailing Address
First Line	:	146 THUNDER RIDGE DR
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-7762
Country	:	US
Telephone Number	:	518-801-6446
Fax Number	:

Provider Business Practice Location Address
First Line	:	56 N COLLEGE AVE UNIT 2A
Second Line	:
City	:	COLLEGE PLACE
State	:	WA
Zip	:	99324-1048
Country	:	US
Telephone Number	:	509-730-0728
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2012
Last Update Date	:	01/24/2025

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