Provider Demographics
NPI:1275964918
Name:ALEKSANDR KOMAROV DPM LLC
Entity Type:Organization
Organization Name:ALEKSANDR KOMAROV DPM LLC
Other - Org Name:LANSING FOOT & ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO, SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEKSANDR
Authorized Official - Middle Name:
Authorized Official - Last Name:KOMAROV
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-787-9684
Mailing Address - Street 1:1360 N LAKE SHORE DR APT 708
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-8442
Mailing Address - Country:US
Mailing Address - Phone:248-787-3625
Mailing Address - Fax:
Practice Address - Street 1:1360 N LAKE SHORE DR APT 708
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-8442
Practice Address - Country:US
Practice Address - Phone:248-787-3625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-05
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty