Provider Demographics
NPI:1326128422
Name:ICATAR, JULIANNE YANTACHKA (MD)
Entity Type:Individual
Prefix:
First Name:JULIANNE
Middle Name:YANTACHKA
Last Name:ICATAR
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 1:15 PROWITT ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06855-1203
Mailing Address - Country:US
Mailing Address - Phone:203-299-0792
Mailing Address - Fax:
Practice Address - Street 1:89 HART ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-5048
Practice Address - Country:US
Practice Address - Phone:203-579-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039643207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001396432Medicaid
160002087Medicare ID - Type Unspecified
H40874Medicare UPIN