Basic Information
| Provider Information | |||||||||
| NPI: | 1598927824 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARKOV | ||||||||
| FirstName: | NICKOLAY | ||||||||
| MiddleName: | PETER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 88MDG/SGHJ | ||||||||
| Address2: | 4881 SUGAR MAPLE DR. | ||||||||
| City: | WRIGHT PATTERSON AFB | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372576529 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4881 SUGAR MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | WPAFB | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454335529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372559922 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2008 | ||||||||
| LastUpdateDate: | 03/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 25622 | NE | N | Allopathic & Osteopathic Physicians | Surgery | 208200000X | 35.134010 | OH | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 390200000X | 01 | TX | STUDENT IN AN ORGANIZED HEALTH CARE EDUCATION/TRAINING PROGRAM | OTHER | 0376798 | 05 | OH | MEDICAID |