Healthcare Provider Details

I. General information

NPI: 1578851432
Provider Name (Legal Business Name): MARIJA ZHUKOV MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2011
Last Update Date: 07/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 CHALKSTONE AVE
PROVIDENCE RI
02908-4728
US

IV. Provider business mailing address

PO BOX 6064
PROVIDENCE RI
02940-6064
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-2666
  • Fax: 401-490-7534
Mailing address:
  • Phone: 401-490-7551
  • Fax: 401-490-7534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD13636
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: