Provider Demographics
NPI:1598743817
Name:CHERVENKOV, KRISTIYAN S (MD)
Entity type:Individual
Prefix:
First Name:KRISTIYAN
Middle Name:S
Last Name:CHERVENKOV
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 1:1901 REDROCK DR
Mailing Address - Street 2:PFS DEPT
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5683
Mailing Address - Country:US
Mailing Address - Phone:505-863-7000
Mailing Address - Fax:
Practice Address - Street 1:320 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1836
Practice Address - Country:US
Practice Address - Phone:860-928-6541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0686207L00000X
CT47444207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ949224OtherAHCCCS
NMNM009W13OtherBC/BS
NM10019724OtherLOVELACE HEALTH/SALUD
NM20054726Medicaid
NMQMYPR0068285OtherMOLINA
NM202000056OtherPRESBYTERIAN HEALTH/SALUD