Provider Demographics
NPI:1285695031
Name:KANTROWITZ, NIKI E (MD)
Entity type:Individual
Prefix:
First Name:NIKI
Middle Name:E
Last Name:KANTROWITZ
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 1:111 MARYS AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-5896
Mailing Address - Country:US
Mailing Address - Phone:845-339-3663
Mailing Address - Fax:845-331-7178
Practice Address - Street 1:111 MARYS AVE STE 3
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-5896
Practice Address - Country:US
Practice Address - Phone:845-339-3663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD193221207RC0001X
KY51403207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100543970Medicaid
NY00972972Medicaid
IN300015505Medicaid