Provider Demographics
NPI:1629022157
Name:PRYTKOV, ALEXEI MIKHAILOVICH (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:ALEXEI
Middle Name:MIKHAILOVICH
Last Name:PRYTKOV
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10870 US ONE N UNIT 104
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-7804
Mailing Address - Country:US
Mailing Address - Phone:904-438-2720
Mailing Address - Fax:904-212-1711
Practice Address - Street 1:10870 US ONE N UNIT 104
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-7804
Practice Address - Country:US
Practice Address - Phone:904-438-2720
Practice Address - Fax:904-212-1711
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123293207P00000X, 207Q00000X
FLFP6183076207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017980600Medicaid
FLUJG97OtherBCBS
OKOK402171Medicare PIN
OK1629022157OtherBCBS
OK200106190AMedicaid