Provider Demographics
NPI:1851851950
Name:DERADKE, ALEXANDER CHRISTOPHER (DO)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:CHRISTOPHER
Last Name:DERADKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MSC 10-5550 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-4661
Mailing Address - Fax:
Practice Address - Street 1:MSC 10-5550 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-4661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-23
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDO2022-0123207R00000X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine