Healthcare Provider Details

I. General information

NPI: 1245594902
Provider Name (Legal Business Name): ALEJANDRO DAVIDENKO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1343 W MAIN ST A&B
MERCED CA
95340-4438
US

IV. Provider business mailing address

621 14TH ST A&B
MODESTO CA
95354-2504
US

V. Phone/Fax

Practice location:
  • Phone: 209-725-1060
  • Fax:
Mailing address:
  • Phone: 209-529-8519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: