Provider Demographics
NPI:1609036771
Name:VELYCHKO, INNA V (MD)
Entity Type:Individual
Prefix:
First Name:INNA
Middle Name:V
Last Name:VELYCHKO
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 226
Mailing Address - Street 2:
Mailing Address - City:BRUSH PRAIRIE
Mailing Address - State:WA
Mailing Address - Zip Code:98606-0226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9300 SE 91ST AVE STE 201
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97086-3762
Practice Address - Country:US
Practice Address - Phone:503-387-7111
Practice Address - Fax:503-567-7706
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD183825207Q00000X
OH57.012943207Q00000X
WAMD60155804207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0265038OtherL & I
WA1609036771Medicaid
WAG8892681Medicare UPIN