Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 30466 | TX |
Y | 1223G0001X | General Practice | 051337 | NY |
Y | 213EG0000X | General Practice | 051337 | NY |
NPI | 1003964339 |
---|---|
Provider Name | Dr. Vlada Matytsin |
First Address | Sugar Land, TX 77479-3403 |
Second Address | Sugar Land, TX 77479 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/01/2007 |
Last Update Date | 13/08/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02608157 | (05) | NY |
3403552-04 | (05) | TX |
3403552-05 | (05) | TX |
3403552-06 | (05) | TX |