Provider Demographics
NPI:1720510175
Name:SKOROHODOVA, KSENIA (MD)
Entity type:Individual
Prefix:
First Name:KSENIA
Middle Name:
Last Name:SKOROHODOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KSENIA
Other - Middle Name:
Other - Last Name:SKOROKHODOVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:703 RIVERWAY PL
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6745
Mailing Address - Country:US
Mailing Address - Phone:603-627-1661
Mailing Address - Fax:603-669-6944
Practice Address - Street 1:703 RIVERWAY PL
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6745
Practice Address - Country:US
Practice Address - Phone:603-627-1661
Practice Address - Fax:603-669-6944
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH331062085R0202X
390200000X
NY3156712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program