Provider Demographics
NPI:1366701401
Name:STOLETNIY, KATIA SIREL (MD)
Entity type:Individual
Prefix:
First Name:KATIA
Middle Name:SIREL
Last Name:STOLETNIY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25991 HINCKLEY ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3947
Mailing Address - Country:US
Mailing Address - Phone:909-528-6459
Mailing Address - Fax:
Practice Address - Street 1:1805 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1214
Practice Address - Country:US
Practice Address - Phone:909-887-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1342532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry