Provider Demographics
NPI:1336159490
Name:GUSMAN, MIKHAIL (MD)
Entity type:Individual
Prefix:DR
First Name:MIKHAIL
Middle Name:
Last Name:GUSMAN
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 1:79 TAMARACK RD
Mailing Address - Street 2:PO BOX 340
Mailing Address - City:GREENFIELD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12435-0340
Mailing Address - Country:US
Mailing Address - Phone:845-210-1473
Mailing Address - Fax:
Practice Address - Street 1:79 TAMARACK RD
Practice Address - Street 2:
Practice Address - City:GREENFIELD PARK
Practice Address - State:NY
Practice Address - Zip Code:12435-0340
Practice Address - Country:US
Practice Address - Phone:845-210-1473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215332207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02050984Medicaid
NY55C491Medicare ID - Type Unspecified
NYH10368Medicare UPIN