Basic Information
| Provider Information | |||||||||
| NPI: | 1780647552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHEBOTAREV | ||||||||
| FirstName: | OLEG | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2073 KLOCKNER RD | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086903414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095841212 | ||||||||
| FaxNumber: | 6095840103 | ||||||||
| Practice Location | |||||||||
| Address1: | 1818 N MEADE ST | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549113454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207318900 | ||||||||
| FaxNumber: | 9207385369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 01/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 25MA08401100 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 21600 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 223052989 | 01 | TAX ID | OTHER | 0163431 | 05 | NJ | MEDICAID |