Provider Demographics
NPI:1235417551
Name:KATYSHEV, VLADIMIR (MD)
Entity Type:Individual
Prefix:DR
First Name:VLADIMIR
Middle Name:
Last Name:KATYSHEV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E DUNLAP AVE STE 1-279
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-7805
Mailing Address - Country:US
Mailing Address - Phone:313-745-4275
Mailing Address - Fax:
Practice Address - Street 1:250 E DUNLAP AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2825
Practice Address - Country:US
Practice Address - Phone:313-745-4275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ53271207RC0200X, 2084N0400X, 2084V0102X, 2084A2900X
MI43010986162084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical Care
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ53271OtherARIZONA MEDICAL BOARD