Provider Demographics
NPI:1831262724
Name:DEMIANENKO, MICHAEL JAMES (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:DEMIANENKO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16163 COUNTY ROUTE 156
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5746
Mailing Address - Country:US
Mailing Address - Phone:315-779-2828
Mailing Address - Fax:315-782-5813
Practice Address - Street 1:16163 COUNTY ROUTE 156
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5746
Practice Address - Country:US
Practice Address - Phone:315-779-2828
Practice Address - Fax:315-782-5813
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008072-1111N00000X
PADC006671-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC08072-3WOtherNY STATE WORKERS COMPENSA
NY10925625OtherCAQH PROVIDER ID#
NYIA0762Medicare PIN
NYU62225Medicare UPIN