Provider Demographics
NPI:1689829418
Name:VDOVYCHENKO, CHARLOTTE B
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:B
Last Name:VDOVYCHENKO
Suffix:
Gender:F
Credentials:
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 59
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-0059
Mailing Address - Country:US
Mailing Address - Phone:817-915-1800
Mailing Address - Fax:682-503-6649
Practice Address - Street 1:2801 BRAZOS BLVD
Practice Address - Street 2:APT 4309
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76039-5435
Practice Address - Country:US
Practice Address - Phone:817-915-1800
Practice Address - Fax:682-503-6649
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-20
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4075246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
1689829418OtherNPI