Basic Information
| Provider Information | |||||||||
| NPI: | 1750744850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHULKOV | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAVYDOV | ||||||||
| OtherFirstName: | MARIA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3000 ARLINGTON AVE | ||||||||
| Address2: | MAIL STOP 1095 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193836462 | ||||||||
| FaxNumber: | 4193836636 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 BEAUBIEN ST STE 2127 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137450972 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2016 | ||||||||
| LastUpdateDate: | 05/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | 4351045027 | MI | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.