Provider Demographics
NPI:1770187502
Name:ASTAFIEV, ALEXANDER
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:ASTAFIEV
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 1:500 E OLIVE AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-2171
Mailing Address - Country:US
Mailing Address - Phone:818-861-7902
Mailing Address - Fax:818-861-7385
Practice Address - Street 1:500 E OLIVE AVE STE 103
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91501-2171
Practice Address - Country:US
Practice Address - Phone:818-861-7902
Practice Address - Fax:818-861-7385
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1603015574OtherDRIVERS LICENSE