Provider Demographics
NPI:1467401554
Name:FEDOROV, ALEC (MD)
Entity Type:Individual
Prefix:
First Name:ALEC
Middle Name:
Last Name:FEDOROV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:IGOR
Other - Middle Name:
Other - Last Name:FYODOROV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1648
Mailing Address - Country:US
Mailing Address - Phone:541-242-4812
Mailing Address - Fax:541-242-4813
Practice Address - Street 1:1435 G ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4113
Practice Address - Country:US
Practice Address - Phone:541-242-4812
Practice Address - Fax:541-242-4813
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22265207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD22265OtherSTATE LICENSE
OR288355Medicaid
ORG91607Medicare UPIN
R158030Medicare PIN