Healthcare Provider Details

I. General information

NPI: 1386870889
Provider Name (Legal Business Name): EVGENIY KREYDIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 SAN PABLO ST FL 5
LOS ANGELES CA
90033-5313
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 323-865-3700
  • Fax:
Mailing address:
  • Phone: 323-865-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number01094143A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01094143A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA133167
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: