Healthcare Provider Details

I. General information

NPI: 1821087719
Provider Name (Legal Business Name): LEONID M. KATKOVSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15301 WARREN SHINGLE RD 9TH MDG
BEALE AFB CA
95903-1907
US

IV. Provider business mailing address

15301 WARREN SHINGLE RD 9TH MDG
BEALE AFB CA
95903-1907
US

V. Phone/Fax

Practice location:
  • Phone: 530-634-4730
  • Fax:
Mailing address:
  • Phone: 530-634-4730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number77555
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: