Provider Demographics
NPI:1104877836
Name:KOCHLATYI, SERGEI (MD)
Entity type:Individual
Prefix:DR
First Name:SERGEI
Middle Name:
Last Name:KOCHLATYI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CRESSKILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07626-2002
Mailing Address - Country:US
Mailing Address - Phone:917-974-7172
Mailing Address - Fax:201-313-8888
Practice Address - Street 1:110 5TH ST
Practice Address - Street 2:
Practice Address - City:CRESSKILL
Practice Address - State:NJ
Practice Address - Zip Code:07626-2002
Practice Address - Country:US
Practice Address - Phone:917-974-7172
Practice Address - Fax:201-313-8888
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218265207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02142469Medicaid
NY024AI1Medicare ID - Type Unspecified
NYH35434Medicare UPIN