Healthcare Provider Details

I. General information

NPI: 1700684644
Provider Name (Legal Business Name): SERGEY PLOSHCHADIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 03/06/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8301 N CENTRAL EXPY
DALLAS TX
75225-4409
US

IV. Provider business mailing address

2207 NUGENT DR
MANSFIELD TX
76063-5127
US

V. Phone/Fax

Practice location:
  • Phone: 865-392-2811
  • Fax:
Mailing address:
  • Phone: 512-909-8324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number217874
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: