Provider Demographics
NPI:1144417247
Name:SELIVANOV, ALEXANDER
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:SELIVANOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 E TROPICANA AVE STE M
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-7341
Mailing Address - Country:US
Mailing Address - Phone:702-436-1717
Mailing Address - Fax:702-438-1718
Practice Address - Street 1:3510 E TROPICANA AVE STE M
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-7341
Practice Address - Country:US
Practice Address - Phone:702-436-1717
Practice Address - Fax:702-438-1718
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2000143.424332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV6020280001Medicare NSC