Provider Demographics
NPI:1851778005
Name:KOROGODA, VADIM
Entity Type:Individual
Prefix:
First Name:VADIM
Middle Name:
Last Name:KOROGODA
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 1:4534 FALLOWOOD TER
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-9495
Mailing Address - Country:US
Mailing Address - Phone:336-875-6530
Mailing Address - Fax:
Practice Address - Street 1:4534 FALLOWOOD TER
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-9495
Practice Address - Country:US
Practice Address - Phone:336-875-6530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103691367500000X
NY576032367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered