Provider Demographics
NPI:1376176594
Name:BONDARCHUK, GEORGIY O (DIVE IDC)
Entity Type:Individual
Prefix:
First Name:GEORGIY
Middle Name:O
Last Name:BONDARCHUK
Suffix:
Gender:M
Credentials:DIVE IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 HEWITT DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23459-8523
Mailing Address - Country:US
Mailing Address - Phone:757-462-3991
Mailing Address - Fax:
Practice Address - Street 1:1465 HEWITT DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23459-8523
Practice Address - Country:US
Practice Address - Phone:757-462-3991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
1801350442OtherNPPES