Individual
MARYANA YEVTUKH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
10400 75TH ST, KENOSHA, WI 53142
(262) 948-7000
(414) 385-4436
Mailing address
10400 75TH ST, KENOSHA, WI 53142-7884
(262) 948-7000
(414) 385-4436
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
036.143411
IL
207Q00000X
Family Medicine Physician
Primary
69990
WI
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100081565
—
WI
Enumeration date
06/25/2014
Last updated
02/08/2023
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