1700821410 NPI number — DR. VIKTOR YETIMOVICH KAGAN

Table of content: DR. VIKTOR YETIMOVICH KAGAN (NPI 1700821410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700821410 NPI number — DR. VIKTOR YETIMOVICH KAGAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KAGAN
Provider First Name:
VIKTOR
Provider Middle Name:
YETIMOVICH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700821410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 835062
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHARDSON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75083-5062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-796-8765
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4715 VIEWRIDGE AVE
Provider Second Line Business Practice Location Address:
230
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-1658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-257-8715
Provider Business Practice Location Address Fax Number:
800-819-1655
Provider Enumeration Date:
06/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  32375 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00140372 . This is a "RAIL ROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 168675001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 86918A . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 168675002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".