Healthcare Provider Details

I. General information

NPI: 1295885861
Provider Name (Legal Business Name): V.LOSHAKOV, MD & ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 11/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 E BROAD ST
HAZLETON PA
18201-5622
US

IV. Provider business mailing address

1730 E BROAD ST
HAZLETON PA
18201-5622
US

V. Phone/Fax

Practice location:
  • Phone: 570-455-3656
  • Fax:
Mailing address:
  • Phone: 570-455-3656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD419480
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: VADIM LOSHAKOV
Title or Position: OWNER
Credential: MD
Phone: 570-455-3656