Healthcare Provider Details

I. General information

NPI: 1407826803
Provider Name (Legal Business Name): VYACHESLAV ISAKOV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29640 EUCLID AVE
WICKLIFFE OH
44092-1829
US

IV. Provider business mailing address

29640 EUCLID AVE
WICKLIFFE OH
44092-1829
US

V. Phone/Fax

Practice location:
  • Phone: 440-585-2221
  • Fax: 440-585-0249
Mailing address:
  • Phone: 440-585-2221
  • Fax: 440-585-0249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35086279
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: