Healthcare Provider Details

I. General information

NPI: 1811529969
Provider Name (Legal Business Name): ALEKSANDR VOLK SERGOJAN SO-IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8810 SOUTH ST SE
ALBUQUERQUE NM
87117-0001
US

IV. Provider business mailing address

2734 HYDER AVE SE
ALBUQUERQUE NM
87106-3033
US

V. Phone/Fax

Practice location:
  • Phone: 505-846-2761
  • Fax:
Mailing address:
  • Phone: 505-846-2761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: