Provider Demographics
NPI:1376819367
Name:DEMINA, OLGA VICTOROVNA (DO)
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:VICTOROVNA
Last Name:DEMINA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 WEST CONGRESS PKWY
Mailing Address - Street 2:KELLOGG BUILDING FLOOR 3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 NE MOTHER JOSEPH PL STE 400
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-514-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-24
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036136318207RC0000X
WAOP60834432207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease