Provider Demographics
NPI:1225692718
Name:NOVIKOV, ALEXANDRE VICTOR
Entity Type:Individual
Prefix:
First Name:ALEXANDRE
Middle Name:VICTOR
Last Name:NOVIKOV
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 1:175 E CHESTER PIKE
Mailing Address - Street 2:
Mailing Address - City:RIDLEY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19078-2212
Mailing Address - Country:US
Mailing Address - Phone:610-595-6467
Mailing Address - Fax:
Practice Address - Street 1:175 E CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:RIDLEY PARK
Practice Address - State:PA
Practice Address - Zip Code:19078-2212
Practice Address - Country:US
Practice Address - Phone:610-595-6467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1186092085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty