Healthcare Provider Details

I. General information

NPI: 1225338718
Provider Name (Legal Business Name): KSENYA SHLIAKHTSITSAVA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2010
Last Update Date: 08/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 CHILDRENS WAY 2-WEST
SAN DIEGO CA
92123
US

IV. Provider business mailing address

5323 HARRY HINES BLVD # MC9063
DALLAS TX
75390-7208
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-5811
  • Fax:
Mailing address:
  • Phone: 214-648-3896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA125300
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberR8483
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: