Provider Demographics
NPI:1972035632
Name:ELMURODOV, OTABEK (MD)
Entity Type:Individual
Prefix:DR
First Name:OTABEK
Middle Name:
Last Name:ELMURODOV
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 1:1010 7650 E
Mailing Address - Street 2:
Mailing Address - City:CROW AGENCY
Mailing Address - State:MT
Mailing Address - Zip Code:59022
Mailing Address - Country:US
Mailing Address - Phone:206-335-0684
Mailing Address - Fax:
Practice Address - Street 1:760 HOSPITAL CIRCLE
Practice Address - Street 2:7 NEW HOSPITAL CIRCLE
Practice Address - City:BROWNING
Practice Address - State:MT
Practice Address - Zip Code:59417-5941
Practice Address - Country:US
Practice Address - Phone:406-338-8903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA081428207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI39STUDENTOtherSINAI-GRACE HOSPITAL/DMC - TRANSITIONAL YEAR RESIDENCY PROGRAM
MI1972035632Medicaid