Provider Demographics
NPI:1699099671
Name:TERUSHKIN, VITALY
Entity type:Individual
Prefix:
First Name:VITALY
Middle Name:
Last Name:TERUSHKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E 69TH ST APT 1C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-5437
Mailing Address - Country:US
Mailing Address - Phone:212-772-3600
Mailing Address - Fax:
Practice Address - Street 1:205 E 69TH ST APT 1C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5437
Practice Address - Country:US
Practice Address - Phone:212-772-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-20
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD451382207N00000X
NJ25MA09654300207ND0101X, 207N00000X
NY269373207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology