Healthcare Provider Details

I. General information

NPI: 1841453156
Provider Name (Legal Business Name): ALEXANDER USMANOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON STREET HOUSE STAFF OFFICE CP 21005
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

11234 ANDERSON STREET HOUSE STAFF OFFICE CP 21005
LOMA LINDA CA
92354-2804
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-8131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number63636
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: