Provider Demographics
NPI:1467441774
Name:ANDRIANOV, ALEXANDRE GENNADIEVICH (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDRE
Middle Name:GENNADIEVICH
Last Name:ANDRIANOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W MAIN ST
Mailing Address - Street 2:STE 350
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-3025
Mailing Address - Country:US
Mailing Address - Phone:516-297-1753
Mailing Address - Fax:
Practice Address - Street 1:194 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1428
Practice Address - Country:US
Practice Address - Phone:207-834-3155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME016796207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
061454OtherANTHEM
061454OtherANTHEM