Healthcare Provider Details

I. General information

NPI: 1124989017
Provider Name (Legal Business Name): MAKSIM MOKRUSHIN R.T.(MR)(ARRT)
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2025
Last Update Date: 11/25/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 VILLA ROSA WAY
ELK GROVE CA
95758-6138
US

IV. Provider business mailing address

5820 VILLA ROSA WAY
ELK GROVE CA
95758-6138
US

V. Phone/Fax

Practice location:
  • Phone: 916-230-3437
  • Fax:
Mailing address:
  • Phone: 916-230-3437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number1106772
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: