Provider Demographics
NPI:1154797462
Name:CHERNYSHOV, ELVIS
Entity type:Individual
Prefix:DR
First Name:ELVIS
Middle Name:
Last Name:CHERNYSHOV
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 1:355 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-4321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36243 INLAND VALLEY DR STE 160
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-9548
Practice Address - Country:US
Practice Address - Phone:951-698-8821
Practice Address - Fax:951-677-3975
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-20
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA155445207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ390200000XOtherJERSEY CITY MEDICAL CENTER