Basic Information
| Provider Information | |||||||||
| NPI: | 1881031243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LATYSHENKO | ||||||||
| FirstName: | ILYA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36000 DARNALL LOOP | ||||||||
| Address2: | ATTN:MCXI-DEM | ||||||||
| City: | FORT HOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765445095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542888303 | ||||||||
| FaxNumber: | 2542867055 | ||||||||
| Practice Location | |||||||||
| Address1: | 36000 DARNALL LOOP | ||||||||
| Address2: | ATTN: MCXI-DEM | ||||||||
| City: | FORT HOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765445095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542888303 | ||||||||
| FaxNumber: | 2542867055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2013 | ||||||||
| LastUpdateDate: | 09/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2018-00158 | NC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.