Provider Demographics
NPI:1134640899
Name:VERETENNIKOV, SERGEY VLADLENOVICH
Entity Type:Individual
Prefix:
First Name:SERGEY
Middle Name:VLADLENOVICH
Last Name:VERETENNIKOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7248 S LAND PARK DR STE 205
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-3661
Mailing Address - Country:US
Mailing Address - Phone:916-371-4939
Mailing Address - Fax:916-392-2722
Practice Address - Street 1:7248 S LAND PARK DR STE 205
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831-3661
Practice Address - Country:US
Practice Address - Phone:916-371-4939
Practice Address - Fax:916-392-2722
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA180890207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program