Provider Demographics
NPI:1003143801
Name:FEOKTISTOV, ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:
Last Name:FEOKTISTOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 WAUKEGAN RD STE 300
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-2744
Mailing Address - Country:US
Mailing Address - Phone:773-948-7557
Mailing Address - Fax:773-948-7558
Practice Address - Street 1:191 WAUKEGAN RD STE 300
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-2744
Practice Address - Country:US
Practice Address - Phone:773-948-7557
Practice Address - Fax:773-948-7558
Is Sole Proprietor?:No
Enumeration Date:2009-11-16
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036124141207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine