MEDICARE: SERGEY VLADLENOVICH VERETENNIKOV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207Q00000X	Family Medicine Physician	A180890	CA

General Provider Information

NPI Number	:	1134640899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SERGEY VLADLENOVICH VERETENNIKOV

Provider Business Mailing Address
First Line	:	7248 S LAND PARK DR STE 205
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95831-3661
Country	:	US
Telephone Number	:	916-371-4939
Fax Number	:	916-392-2722

Provider Business Practice Location Address
First Line	:	7248 S LAND PARK DR STE 205
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95831-3661
Country	:	US
Telephone Number	:	916-371-4939
Fax Number	:	916-392-2722

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2017
Last Update Date	:	10/27/2022

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