Provider Demographics
NPI:1306876602
Name:PERTSOVSKY, KONSTANTIN (DO)
Entity type:Individual
Prefix:
First Name:KONSTANTIN
Middle Name:
Last Name:PERTSOVSKY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 LAFAYETTE AVE
Mailing Address - Street 2:APT.A
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-2024
Mailing Address - Country:US
Mailing Address - Phone:201-840-4081
Mailing Address - Fax:201-840-4081
Practice Address - Street 1:510 HAMBURG TPKE
Practice Address - Street 2:WAYNE COMMONS, SUITE 101
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2025
Practice Address - Country:US
Practice Address - Phone:973-942-6005
Practice Address - Fax:973-942-6009
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07552900207R00000X
NY214845204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0157376Medicaid
NJ104666PWSMedicare PIN
NJ0157376Medicaid