Provider Demographics
NPI:1114356557
Name:STALEV, VLADIMIR (REGISTERED SA)
Entity Type:Individual
Prefix:
First Name:VLADIMIR
Middle Name:
Last Name:STALEV
Suffix:
Gender:M
Credentials:REGISTERED SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5978 N LINCOLN AVE APT 2C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3747
Mailing Address - Country:US
Mailing Address - Phone:847-415-2850
Mailing Address - Fax:
Practice Address - Street 1:5978 N LINCOLN AVE APT 2C
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3747
Practice Address - Country:US
Practice Address - Phone:847-415-2850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238.000203246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist