Provider Demographics
NPI:1548614589
Name:ERMOLOVICH, EUGENE VLADIMIR (MD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:VLADIMIR
Last Name:ERMOLOVICH
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-2030
Mailing Address - Fax:239-343-4116
Practice Address - Street 1:507 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2618
Practice Address - Country:US
Practice Address - Phone:239-424-2030
Practice Address - Fax:239-343-4116
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME150099208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110688400Medicaid