1700849494 NPI number — DR. RAISA PUSTYLNIKOV M.D.

Table of content: DR. RAISA PUSTYLNIKOV M.D. (NPI 1700849494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700849494 NPI number — DR. RAISA PUSTYLNIKOV M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUSTYLNIKOV
Provider First Name:
RAISA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700849494
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1840 E 14TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11229-2800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-680-1600
Provider Business Mailing Address Fax Number:
718-680-4473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1840 E 14TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11229-2800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-680-1600
Provider Business Practice Location Address Fax Number:
718-680-4473
Provider Enumeration Date:
04/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  206096 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4985397 . This is a "CIGNA PPO, HMO, EPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4C6646 . This is a "HEALTH NET(HMO)" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 857141 . This is a "EMPIRE BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01733586 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: BK00611 04 . This is a "AMERICHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 102086 . This is a "HERITAGE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 11-3552139 . This is a "PHCS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 206096 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 13252 . This is a "ELDER PLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2595569 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P2115470 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 11-3552139 . This is a "1199 NBF" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2422571 . This is a "AETNA HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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