Provider Demographics
NPI:1902926439
Name:KVICHKO, ELENA R (MD)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:R
Last Name:KVICHKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELENA
Other - Middle Name:R
Other - Last Name:KVITCHKO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:28364 S WESTERN AVE # 494
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-1434
Mailing Address - Country:US
Mailing Address - Phone:818-618-2412
Mailing Address - Fax:714-893-3262
Practice Address - Street 1:5762 BOLSA AVE STE 107
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-1172
Practice Address - Country:US
Practice Address - Phone:714-898-0362
Practice Address - Fax:714-893-3262
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA895322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
486059932OtherUNITES STATES OF AMERICA PASSPORT
CAA8771500OtherCALIFORNIA DRIVER LICENSE