Provider Demographics
NPI:1699854224
Name:AKSENOV, IGOR VIKTOROVICH (MD)
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:VIKTOROVICH
Last Name:AKSENOV
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 1:4700 WATERS AVE STE 507
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-4750
Mailing Address - Fax:912-350-4751
Practice Address - Street 1:4700 WATERS AVE STE 507
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-4750
Practice Address - Fax:912-350-4751
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94813207RP1001X, 207RC0200X
GA062644207RP1001X, 207R00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
01286490OtherAMERIGROUP
GA518768OtherWELLCARE
GA321479371BMedicaid
GA321479371AMedicaid
GAP00733491OtherRAILROAD MEDICARE
SCG62644Medicaid
GA202I292515Medicare PIN