Provider Demographics
NPI:1215474440
Name:ZHIDETSKIY, ALEKSANDR (DPT)
Entity type:Individual
Prefix:
First Name:ALEKSANDR
Middle Name:
Last Name:ZHIDETSKIY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 CORONADO AVE
Mailing Address - Street 2:APT 17
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814-2671
Mailing Address - Country:US
Mailing Address - Phone:562-761-9942
Mailing Address - Fax:
Practice Address - Street 1:355 CORONADO AVE
Practice Address - Street 2:APT 17
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90814-2671
Practice Address - Country:US
Practice Address - Phone:562-761-9942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist