Basic Information
Provider Information | |||||||||
NPI: | 1487183539 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POCHTAREV | ||||||||
FirstName: | VERA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1811 W 14 MILE RD UNIT 206 | ||||||||
Address2: |   | ||||||||
City: | ROYAL OAK | ||||||||
State: | MI | ||||||||
PostalCode: | 480731757 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4144460481 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1101 W UNIVERSITY DR | ||||||||
Address2: |   | ||||||||
City: | ROCHESTER | ||||||||
State: | MI | ||||||||
PostalCode: | 483071863 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2486014805 | ||||||||
FaxNumber: | 2486014908 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2017 | ||||||||
LastUpdateDate: | 11/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 4301112290 | MI | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207R00000X | 147406 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 4301112290 | 01 | MI | MEDICAL DOCTOR - EDUCATIONAL LIMITED | OTHER |