Provider Demographics
NPI:1992787089
Name:LARTCHENKO, SERGE (MD)
Entity type:Individual
Prefix:DR
First Name:SERGE
Middle Name:
Last Name:LARTCHENKO
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 1:2821 E PRESIDENT GEORGE BUSH HWY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-4266
Mailing Address - Country:US
Mailing Address - Phone:469-206-6957
Mailing Address - Fax:469-206-6953
Practice Address - Street 1:2821 E PRESIDENT GEORGE BUSH HWY
Practice Address - Street 2:SUITE 500
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-4266
Practice Address - Country:US
Practice Address - Phone:469-206-6957
Practice Address - Fax:469-206-6953
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8115174400000X, 207RI0200X
LA026361207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1043443Medicaid
I20177Medicare UPIN