Provider Demographics
NPI:1184652760
Name:POPOV, ALEXANDER
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:POPOV
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 1:12512 VICTORY BLVD
Mailing Address - Street 2:#D
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3180
Mailing Address - Country:US
Mailing Address - Phone:818-753-9994
Mailing Address - Fax:818-753-8621
Practice Address - Street 1:12512 VICTORY BLVD
Practice Address - Street 2:#D
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3180
Practice Address - Country:US
Practice Address - Phone:818-753-9994
Practice Address - Fax:818-753-8621
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78244208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A782440Medicare ID - Type UnspecifiedMEDICAL CLINIC
CAA78244CMedicare PIN