Basic Information
Provider Information | |||||||||
NPI: | 1457779944 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | YESAULAVA | ||||||||
FirstName: | LIUDMILA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 936857 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 311936857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9106629300 | ||||||||
FaxNumber: | 9106622401 | ||||||||
Practice Location | |||||||||
Address1: | 1725 NEW HANOVER MEDICAL PARK DR | ||||||||
Address2: |   | ||||||||
City: | WILMINGTON | ||||||||
State: | NC | ||||||||
PostalCode: | 284035345 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9106629300 | ||||||||
FaxNumber: | 9106622401 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/01/2014 | ||||||||
LastUpdateDate: | 07/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2018-01980 | NC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 78251 | GA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 390200000X | 200999 | NC | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207RE0101X | 2018-01980 | NC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
ID | Type | State | Issuer | Description | 2018-01980 | 01 | NC | STATE LICENSE | OTHER | FY6842454 | 01 | NC | DEA | OTHER |