Provider Demographics
NPI:1770841421
Name:SELEVERSTOV, OLEKSANDR (MD)
Entity Type:Individual
Prefix:DR
First Name:OLEKSANDR
Middle Name:
Last Name:SELEVERSTOV
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 1:146 THUNDER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-7762
Mailing Address - Country:US
Mailing Address - Phone:518-801-6446
Mailing Address - Fax:
Practice Address - Street 1:1129 S 2ND AVE STE B
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4100
Practice Address - Country:US
Practice Address - Phone:509-520-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61002582207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine