Provider Demographics
NPI:1881822898
Name:YEVSEYENKOV, VLADIMIR V (OD, PHD)
Entity Type:Individual
Prefix:
First Name:VLADIMIR
Middle Name:V
Last Name:YEVSEYENKOV
Suffix:
Gender:M
Credentials:OD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5865 W UTOPIA RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5251
Mailing Address - Country:US
Mailing Address - Phone:623-806-7226
Mailing Address - Fax:
Practice Address - Street 1:5865 W UTOPIA RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5251
Practice Address - Country:US
Practice Address - Phone:623-806-7226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1782152W00000X
IL046010215152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL502720006Medicare PIN
IL046010215Medicaid