Provider Demographics
NPI:1285649145
Name:SERBINE, OLEG V (MD)
Entity Type:Individual
Prefix:
First Name:OLEG
Middle Name:V
Last Name:SERBINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10966
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86427-0966
Mailing Address - Country:US
Mailing Address - Phone:928-788-3333
Mailing Address - Fax:928-788-3555
Practice Address - Street 1:1510 E WAGON WHEEL LN
Practice Address - Street 2:STE. 110
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-6697
Practice Address - Country:US
Practice Address - Phone:928-788-3333
Practice Address - Fax:928-788-3555
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37626207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ103360Medicaid
AZZ190767Medicare PIN
UTH92192Medicare UPIN