Provider Demographics
NPI:1790075794
Name:KHACHATUROV, VADIM (MD)
Entity Type:Individual
Prefix:
First Name:VADIM
Middle Name:
Last Name:KHACHATUROV
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 1:2646 MAYFIELD RD
Mailing Address - Street 2:APT. 304
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-5509
Mailing Address - Country:US
Mailing Address - Phone:917-656-3056
Mailing Address - Fax:
Practice Address - Street 1:1 GUSTAVE L LEVY PL
Practice Address - Street 2:15TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6500
Practice Address - Country:US
Practice Address - Phone:212-241-8014
Practice Address - Fax:212-426-5129
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301110433207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program