Active NPI
Paul Fedorenko
- Specialist
- West Sacramento, CA
National Provider Identifier
1538407903
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Specialist
- License
- 14279
- Practice address
- 2204 W Capitol Ave
West Sacramento, CA 95691-2425 - Phone
- (916) 572-0811
- Fax
- (916) 572-0813
- NPI assigned
- Jan 19, 2013
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Specialist | 174400000X | 14279 | CA | Primary |
Addresses
Primary practice location
2204 W Capitol Ave
West Sacramento, CA 95691-2425
Mailing address
2204 W Capitol Ave
West Sacramento, CA 95691-2425
Phone (916) 572-0811
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 14279 | CA | MD | Optometrist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1358553600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1358553600000",
"number": "1538407903",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2204 W CAPITOL AVE",
"city": "WEST SACRAMENTO",
"state": "CA",
"postal_code": "956912425",
"telephone_number": "916-572-0811",
"fax_number": "916-572-0813"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2204 W CAPITOL AVE",
"city": "WEST SACRAMENTO",
"state": "CA",
"postal_code": "956912425",
"telephone_number": "916-572-0811",
"fax_number": "916-572-0813"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FEDORENKO",
"first_name": "PAUL",
"name_prefix": "Mr.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2013-01-19",
"last_updated": "2013-01-19",
"status": "A"
},
"taxonomies": [
{
"code": "174400000X",
"taxonomy_group": "",
"desc": "Specialist",
"state": "CA",
"license": "14279",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in West Sacramento, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 19, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.