Basic Information
| Provider Information | |||||||||
| NPI: | 1235417551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KATYSHEV | ||||||||
| FirstName: | VLADIMIR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 E DUNLAP AVE STE 1-279 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850207805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137454275 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 250 E DUNLAP AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850202825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137454275 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2011 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 53271 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 2084N0400X | 53271 | AZ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 4301098616 | MI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084V0102X | 53271 | AZ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology | 2084A2900X | 53271 | AZ | Y |
ID Information
| ID | Type | State | Issuer | Description | 53271 | 01 | AZ | ARIZONA MEDICAL BOARD | OTHER |