Provider Demographics
NPI:1821087719
Name:KATKOVSKY, LEONID M (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONID
Middle Name:M
Last Name:KATKOVSKY
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 1:15301 WARREN SHINGLE RD
Mailing Address - Street 2:9TH MDG
Mailing Address - City:BEALE AFB
Mailing Address - State:CA
Mailing Address - Zip Code:95903-1907
Mailing Address - Country:US
Mailing Address - Phone:530-634-4730
Mailing Address - Fax:
Practice Address - Street 1:15301 WARREN SHINGLE RD
Practice Address - Street 2:9TH MDG
Practice Address - City:BEALE AFB
Practice Address - State:CA
Practice Address - Zip Code:95903-1907
Practice Address - Country:US
Practice Address - Phone:530-634-4730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH77555171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH77555OtherMEDICAL LICENSE