Provider Demographics
NPI:1437290772
Name:YEVDOKIMOVA, OKSANA (MD)
Entity Type:Individual
Prefix:
First Name:OKSANA
Middle Name:
Last Name:YEVDOKIMOVA
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:PO BOX 27957
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0957
Mailing Address - Country:US
Mailing Address - Phone:908-689-0777
Mailing Address - Fax:908-835-3036
Practice Address - Street 1:315 ROUTE 31 SOUTH
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07882-4327
Practice Address - Country:US
Practice Address - Phone:908-689-0777
Practice Address - Fax:908-835-3037
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA8408900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0179949Medicaid
NJ139715Medicare PIN