Provider Demographics
NPI:1326056946
Name:KHANUKOV, EUGENIYA (MD)
Entity Type:Individual
Prefix:
First Name:EUGENIYA
Middle Name:
Last Name:KHANUKOV
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 1:15500 19 MILE RD
Mailing Address - Street 2:SUITE 360
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6330
Mailing Address - Country:US
Mailing Address - Phone:586-263-9999
Mailing Address - Fax:586-263-0581
Practice Address - Street 1:15500 19 MILE RD
Practice Address - Street 2:SUITE 360
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6330
Practice Address - Country:US
Practice Address - Phone:586-263-9999
Practice Address - Fax:586-263-0581
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048104207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4223612Medicaid
OM7790002Medicare ID - Type Unspecified
MI4223612Medicaid