1003874686 NPI number — DR. ALEXANDER VDOVENKO M.D.

Table of content: DR. ALEXANDER VDOVENKO M.D. (NPI 1003874686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003874686 NPI number — DR. ALEXANDER VDOVENKO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VDOVENKO
Provider First Name:
ALEXANDER
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003874686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1730
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06507-1730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-397-8000
Provider Business Mailing Address Fax Number:
203-389-1540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 GRAND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW BRITAIN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06052-2016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-224-5584
Provider Business Practice Location Address Fax Number:
860-224-5946
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  39677 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0007210291 . This is a "AETNA USHC" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 061557734 . This is a "OXFORD GROUP#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0V6399 . This is a "HEALTHNET GROUP#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 615577 . This is a "CONNECTICARE GRP#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 001396771 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500HBL433CT01 . This is a "BC/BS NBG GRP#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004199057P1 . This is a "BLUE CARE NBG GRP#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 500HBL433CT02 . This is a "BC/BS BMH GRP#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 9094684 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004199057P2 . This is a "BLUE CARE BMH GRP#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 1104295 . This is a "UNITED HEALTHCARE GRP#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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