Provider Demographics
NPI:1790860484
Name:GORDIENKO, OLEG E (MD)
Entity Type:Individual
Prefix:
First Name:OLEG
Middle Name:E
Last Name:GORDIENKO
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 1:34509 9TH AVE SO
Mailing Address - Street 2:SUITE #308
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8710
Mailing Address - Country:US
Mailing Address - Phone:253-874-4352
Mailing Address - Fax:253-874-5537
Practice Address - Street 1:34509 9TH AVE SO
Practice Address - Street 2:SUITE #308
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8710
Practice Address - Country:US
Practice Address - Phone:253-874-4352
Practice Address - Fax:253-874-5537
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA208194OtherPHCS
WA35595OtherL & I
WA4078430OtherAETNA
WA1039320Medicaid
WA1039320Medicaid
MA208194OtherPHCS