Provider Demographics
NPI:1093005498
Name:SHEVCHENKO, GENNADIY VASILYEVICH (MD)
Entity Type:Individual
Prefix:
First Name:GENNADIY
Middle Name:VASILYEVICH
Last Name:SHEVCHENKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3809 42ND AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-3503
Mailing Address - Country:US
Mailing Address - Phone:612-721-6261
Mailing Address - Fax:612-721-1691
Practice Address - Street 1:3809 42ND AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-3503
Practice Address - Country:US
Practice Address - Phone:612-721-6261
Practice Address - Fax:612-721-1691
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-19
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN592552084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology