Provider Demographics
NPI:1689237844
Name:KLIASSOV, EVELYNA GEORGE
Entity type:Individual
Prefix:
First Name:EVELYNA
Middle Name:GEORGE
Last Name:KLIASSOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 741087
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1087
Mailing Address - Country:US
Mailing Address - Phone:843-847-4179
Mailing Address - Fax:843-847-4296
Practice Address - Street 1:9330 MEDICAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9104
Practice Address - Country:US
Practice Address - Phone:843-847-4179
Practice Address - Fax:843-847-4296
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2024-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC92942207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty