Provider Demographics
NPI:1356048136
Name:CHESNOKOV, VADIM VLADIMIROVICH
Entity type:Individual
Prefix:
First Name:VADIM
Middle Name:VLADIMIROVICH
Last Name:CHESNOKOV
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 1:419 NE 71ST ST APT 507
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-5878
Mailing Address - Country:US
Mailing Address - Phone:360-977-9631
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC STREET BOX 356410
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-9600
Practice Address - Country:US
Practice Address - Phone:206-543-3687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2024-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61544854208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery