Basic Information
| Provider Information | |||||||||
| NPI: | 1679611826 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHEMELEKOV | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | ROUSSEV | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7415 W CHERRY HILLS DR | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853458795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807260941 | ||||||||
| FaxNumber: | 4807260943 | ||||||||
| Practice Location | |||||||||
| Address1: | 1175 S ARIZONA AVE | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852481504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807260941 | ||||||||
| FaxNumber: | 4807260943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1416 | AZ | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 44673 | 01 | AZ | SPECTERA PROVIDER # | OTHER |