Provider Demographics
NPI:1073812335
Name:ZHUKALIN, MIKHAIL
Entity Type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:
Last Name:ZHUKALIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1648 PIERCE DR. NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-0000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1648 PIERCE DR. NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307
Practice Address - Country:US
Practice Address - Phone:515-770-7556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0754242081P2900X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program