Provider Demographics
NPI:1427025105
Name:FOMITCHEV, OLEG (MD)
Entity Type:Individual
Prefix:DR
First Name:OLEG
Middle Name:
Last Name:FOMITCHEV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:OLEG
Other - Middle Name:
Other - Last Name:FOMITCHEV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:350 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-2840
Mailing Address - Country:US
Mailing Address - Phone:973-365-4489
Mailing Address - Fax:
Practice Address - Street 1:350 BOULEVARD
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-2840
Practice Address - Country:US
Practice Address - Phone:973-365-4489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26893207Q00000X
NJ25MA08109100207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51531294OtherBLUE CROSS BLUE SHIELD
ALI45804Medicare UPIN
AL051531294Medicare ID - Type Unspecified