Provider Demographics
NPI:1013465020
Name:DEMIDOV, PAVEL
Entity Type:Individual
Prefix:
First Name:PAVEL
Middle Name:
Last Name:DEMIDOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 UTICA AVE
Mailing Address - Street 2:STE 259
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3879
Mailing Address - Country:US
Mailing Address - Phone:909-906-1505
Mailing Address - Fax:909-906-1508
Practice Address - Street 1:8300 UTICA AVE
Practice Address - Street 2:STE 259
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3879
Practice Address - Country:US
Practice Address - Phone:909-906-1505
Practice Address - Fax:909-906-1508
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst