Healthcare Provider Details

I. General information

NPI: 1881031243
Provider Name (Legal Business Name): ILYA VLADIMIROVICH LATYSHENKO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2013
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MANNING DR
CHAPEL HILL NC
27514-4220
US

IV. Provider business mailing address

4029 BURNETT-WOMACK BLDG CB #7081
CHAPEL HILL NC
27599-0001
US

V. Phone/Fax

Practice location:
  • Phone: 919-966-7841
  • Fax:
Mailing address:
  • Phone: 919-966-7841
  • Fax: 919-966-4653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2018-00158
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2018-00158
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: