Provider Demographics
NPI:1568979656
Name:ADDISON, ALEXANDER DARKO
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:DARKO
Last Name:ADDISON
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:ALEXANDERADDISON@DBHSBCOUNTYGOV 8320 E GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0001
Mailing Address - Country:US
Mailing Address - Phone:909-387-7200
Mailing Address - Fax:
Practice Address - Street 1:ALEXANDERADDISON@DBHSBCOUNTYGOV 8320 E GILBERT ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-0001
Practice Address - Country:US
Practice Address - Phone:909-387-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA734124163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$OtherREGISTERED NURSE
CA$$$$$$$$$Medicaid