Provider Demographics
NPI:1780647552
Name:CHEBOTAREV, OLEG (MD)
Entity Type:Individual
Prefix:DR
First Name:OLEG
Middle Name:
Last Name:CHEBOTAREV
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 1:2073 KLOCKNER RD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08690-3414
Mailing Address - Country:US
Mailing Address - Phone:609-584-1212
Mailing Address - Fax:609-584-0103
Practice Address - Street 1:1818 N MEADE ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3454
Practice Address - Country:US
Practice Address - Phone:920-731-8900
Practice Address - Fax:920-738-5369
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08401100207RC0000X
WI21600207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
223052989OtherTAX ID
NJ0163431Medicaid
127882CN4Medicare PIN