Provider Demographics
NPI:1124833629
Name:MARTYNENKO, ALEX
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:MARTYNENKO
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 1:1109 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5849
Mailing Address - Country:US
Mailing Address - Phone:817-498-3919
Mailing Address - Fax:
Practice Address - Street 1:1109 CHURCH ST
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5849
Practice Address - Country:US
Practice Address - Phone:817-498-3919
Practice Address - Fax:817-498-7080
Is Sole Proprietor?:No
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1404068208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1404068OtherSTATE LICENSE