Provider Demographics
NPI:1528094133
Name:BLUDOY, BORIS (MD)
Entity type:Individual
Prefix:DR
First Name:BORIS
Middle Name:
Last Name:BLUDOY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BORIS
Other - Middle Name:MIKHAYLOVICH
Other - Last Name:BLYUDOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:745 GILBERT PL
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3125
Mailing Address - Country:US
Mailing Address - Phone:347-249-4816
Mailing Address - Fax:
Practice Address - Street 1:105 ORIENTAL BLVD STE 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-4124
Practice Address - Country:US
Practice Address - Phone:718-646-7174
Practice Address - Fax:718-332-0327
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225883207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02323811Medicaid
NY53S191Medicare ID - Type Unspecified
NY02323811Medicaid