Provider Demographics
NPI:1952449290
Name:AKSENTIJEVICH, SOFIA (MD)
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:AKSENTIJEVICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 E FARMFIELD AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7757
Mailing Address - Country:US
Mailing Address - Phone:843-571-6067
Mailing Address - Fax:843-769-4853
Practice Address - Street 1:14 E FARMFIELD AVENUE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7757
Practice Address - Country:US
Practice Address - Phone:843-571-6067
Practice Address - Fax:843-769-4853
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34312207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC343122Medicaid
SC4551Medicare PIN
G47975Medicare UPIN