Provider Demographics
NPI:1700821410
Name:KAGAN, VIKTOR YETIMOVICH
Entity Type:Individual
Prefix:DR
First Name:VIKTOR
Middle Name:YETIMOVICH
Last Name:KAGAN
Suffix:
Gender:M
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 835062
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75083-5062
Mailing Address - Country:US
Mailing Address - Phone:214-796-8765
Mailing Address - Fax:
Practice Address - Street 1:4715 VIEWRIDGE AVE
Practice Address - Street 2:230
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1658
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32375103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00140372OtherRAIL ROAD
TX168675001Medicaid
TX86918AOtherBLUE CROSS BLUE SHIELD
TX168675002Medicaid
TX168675002Medicaid
TX168675001Medicaid