Provider Demographics
NPI:1356542591
Name:DEMIDENKO, ALEXANDER (DO)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:DEMIDENKO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 SEAGIRT BLVD BSMT FLOOR
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2802
Mailing Address - Country:US
Mailing Address - Phone:810-444-9183
Mailing Address - Fax:
Practice Address - Street 1:2004 SEAGIRT BLVD
Practice Address - Street 2:BASEMENT FLOOR
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-2802
Practice Address - Country:US
Practice Address - Phone:718-868-8668
Practice Address - Fax:718-868-8611
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249146207W00000X, 207W00000X
CT047093207W00000X
MI5101016228207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03195782Medicaid
NY249146OtherLICENSE
NY249146OtherLICENSE
NYG400038011Medicare UPIN
NY249146OtherLICENSE
NYG400038011Medicare UPIN
NYA400041148Medicare UPIN