Provider Demographics
NPI:1356491484
Name:CHERVENAK, A DOUGLAS (DO)
Entity type:Individual
Prefix:
First Name:A
Middle Name:DOUGLAS
Last Name:CHERVENAK
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 1:319 N CARTERS RD
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:DE
Mailing Address - Zip Code:19977-1282
Mailing Address - Country:US
Mailing Address - Phone:302-653-1050
Mailing Address - Fax:302-653-1089
Practice Address - Street 1:671 S CARTER RD STE 12
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-7727
Practice Address - Country:US
Practice Address - Phone:302-653-1050
Practice Address - Fax:302-653-1089
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0003255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE000468803Medicaid
DEE99034Medicare UPIN
G00480Medicare ID - Type Unspecified