Provider Demographics
NPI:1154441749
Name:EVGENOV, OLEG VICTOROVICH (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:OLEG
Middle Name:VICTOROVICH
Last Name:EVGENOV
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 VIRGINIA FARME LN
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:MA
Mailing Address - Zip Code:01741-1343
Mailing Address - Country:US
Mailing Address - Phone:978-390-4930
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:CRB444
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA229154207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology