Provider Demographics
NPI:1932126802
Name:VLACHOS, KATRINA M (MD)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:M
Last Name:VLACHOS
Suffix:
Gender:F
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:PO BOX 757
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-0757
Mailing Address - Country:US
Mailing Address - Phone:310-574-0384
Mailing Address - Fax:310-574-0382
Practice Address - Street 1:13160 MINDANAO WAY #300
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292
Practice Address - Country:US
Practice Address - Phone:310-574-0384
Practice Address - Fax:310-574-0382
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA068888208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
A68888Medicare ID - Type Unspecified
CAH16761Medicare UPIN