Provider Demographics
NPI:1407826803
Name:ISAKOV, VYACHESLAV (MD)
Entity Type:Individual
Prefix:DR
First Name:VYACHESLAV
Middle Name:
Last Name:ISAKOV
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 1:29640 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-1829
Mailing Address - Country:US
Mailing Address - Phone:440-585-2221
Mailing Address - Fax:440-585-0249
Practice Address - Street 1:29640 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WICKLIFFE
Practice Address - State:OH
Practice Address - Zip Code:44092-1829
Practice Address - Country:US
Practice Address - Phone:440-585-2221
Practice Address - Fax:440-585-0249
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35086279207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2595008Medicaid
OH4165551Medicare PIN
OH4165552Medicare PIN
OHP00276439Medicare PIN
OH2595008Medicaid