Provider Demographics
NPI:1245737469
Name:JOLTIKOV, YEKATERINA (MD)
Entity type:Individual
Prefix:
First Name:YEKATERINA
Middle Name:
Last Name:JOLTIKOV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:A
Other - Last Name:JOLTIKOV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1855 W TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1333 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8219
Practice Address - Country:US
Practice Address - Phone:541-779-4711
Practice Address - Fax:541-779-0796
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125075172207W00000X
IL036160156207W00000X
390200000X
ORMD213795207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program