Provider Demographics
NPI:1609368935
Name:KHODAKIVSKYI, SERGII (MD)
Entity Type:Individual
Prefix:
First Name:SERGII
Middle Name:
Last Name:KHODAKIVSKYI
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 1:12 BELMONTE DR
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-9073
Mailing Address - Country:US
Mailing Address - Phone:917-724-7072
Mailing Address - Fax:
Practice Address - Street 1:1150 N INDIAN CANYON DR
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4872
Practice Address - Country:US
Practice Address - Phone:951-764-2863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-01
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA174583207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty