Provider Demographics
NPI:1225338718
Name:SHLIAKHTSITSAVA, KSENYA (MD)
Entity Type:Individual
Prefix:
First Name:KSENYA
Middle Name:
Last Name:SHLIAKHTSITSAVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5323 HARRY HINES BLVD # MC9063
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-7208
Mailing Address - Country:US
Mailing Address - Phone:214-648-3896
Mailing Address - Fax:
Practice Address - Street 1:3010 CHILDRENS WAY
Practice Address - Street 2:2-WEST
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123
Practice Address - Country:US
Practice Address - Phone:858-966-5811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-29
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA125300208000000X
TXR84832080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics