Provider Demographics
NPI:1982868550
Name:MERKULOV, ALEX (MD)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:MERKULOV
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 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:DIGNOSTIC RADIOLOGY
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-2803
Practice Address - Country:US
Practice Address - Phone:860-679-2784
Practice Address - Fax:860-679-4126
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT484172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1982868550Medicaid
CT1982868550Medicaid