Healthcare Provider Details

I. General information

NPI: 1215923990
Provider Name (Legal Business Name): JORGE M DAVIDENKO MD FACC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 HOMER AVE
CORTLAND NY
13045-1206
US

IV. Provider business mailing address

134 HOMER AVE PO BOX 628
CORTLAND NY
13045-1206
US

V. Phone/Fax

Practice location:
  • Phone: 607-756-3561
  • Fax: 607-428-5142
Mailing address:
  • Phone: 607-756-3561
  • Fax: 607-428-5142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number196572
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number196572
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: