Provider Demographics
NPI:1710971551
Name:PODVEZKO, ALEXANDER Y (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:Y
Last Name:PODVEZKO
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 1:601 GATES RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-2288
Mailing Address - Country:US
Mailing Address - Phone:607-772-9462
Mailing Address - Fax:607-772-1223
Practice Address - Street 1:169 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4246
Practice Address - Country:US
Practice Address - Phone:607-798-5223
Practice Address - Fax:607-798-6187
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2292662085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014702920002Medicaid
PA1014702920002Medicaid
NYRA7705Medicare PIN
PAP00453170Medicare PIN