Provider Demographics
NPI:1558377424
Name:FEDENKO, ALEXANDER N (MD)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:N
Last Name:FEDENKO
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-2582
Mailing Address - Fax:
Practice Address - Street 1:1500 SAN PABLO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5313
Practice Address - Country:US
Practice Address - Phone:323-442-2582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56427207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A564270Medicaid
CA1952325565OtherGROUP NPI
CA00A564270OtherBLUE SHIELD
CAHW7801AMedicare PIN
CAWA56427AMedicare PIN
CAG71005Medicare UPIN
CA00A564270Medicaid
CA220024065Medicare UPIN
CA1952325565OtherGROUP NPI
CAWA56427BMedicare PIN