Provider Demographics
NPI:1679987879
Name:DEREVIANKO, ALEXANDRE
Entity Type:Individual
Prefix:
First Name:ALEXANDRE
Middle Name:
Last Name:DEREVIANKO
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 1:1811 ARKANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088-4244
Mailing Address - Country:US
Mailing Address - Phone:401-480-9807
Mailing Address - Fax:847-733-5827
Practice Address - Street 1:1811 ARKANSAS AVE
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-4244
Practice Address - Country:US
Practice Address - Phone:401-480-9807
Practice Address - Fax:847-733-5827
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238000408246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL238000408OtherLICENSE NUMBER