Provider Demographics
NPI:1902898166
Name:CHOUMAROV, GEORGE SR (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:CHOUMAROV
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4522
Mailing Address - Country:US
Mailing Address - Phone:432-332-2332
Mailing Address - Fax:
Practice Address - Street 1:414 E 8TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4522
Practice Address - Country:US
Practice Address - Phone:432-332-2332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4026207R00000X, 208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0081CFOtherBLUE CROSS BLUE SHIELD TX
TX00396GMedicare ID - Type UnspecifiedMEDICARE
TXG62045Medicare UPIN