Provider Demographics
NPI:1215923990
Name:DAVIDENKO, JORGE M (MD FACC)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:M
Last Name:DAVIDENKO
Suffix:
Gender:M
Credentials:MD FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 HOMER AVE
Mailing Address - Street 2:PO BOX 628
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-1206
Mailing Address - Country:US
Mailing Address - Phone:607-756-3561
Mailing Address - Fax:607-428-5142
Practice Address - Street 1:134 HOMER AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1206
Practice Address - Country:US
Practice Address - Phone:607-756-3561
Practice Address - Fax:607-428-5142
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196572207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01979708Medicaid
NYBA0927Medicare UPIN
NY01979708Medicaid
NY060056231Medicare PIN
NYRB6996Medicare PIN