Provider Demographics
NPI:1609281989
Name:YEVTUKH, MARYANA (DO)
Entity Type:Individual
Prefix:
First Name:MARYANA
Middle Name:
Last Name:YEVTUKH
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 1:10400 75TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7884
Mailing Address - Country:US
Mailing Address - Phone:262-948-7000
Mailing Address - Fax:414-385-4436
Practice Address - Street 1:10400 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142
Practice Address - Country:US
Practice Address - Phone:262-948-7000
Practice Address - Fax:414-385-4436
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI69990207Q00000X
IL036.143411207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100081565Medicaid