=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447996947
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VLADISLAV ISKHAKOV PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2022
-----------------------------------------------------
Last Update Date | 08/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6330 PRIMROSE HILL CT
-----------------------------------------------------
City | NORCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30092-4544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-309-8108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6020 GOODWOOD BLVD
-----------------------------------------------------
City | NORCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30093-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-309-8108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT015267
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------