Provider Demographics
NPI:1699757526
Name:RYVKIN, ROSTISLAV (OD)
Entity type:Individual
Prefix:
First Name:ROSTISLAV
Middle Name:
Last Name:RYVKIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 KINGS HWY
Mailing Address - Street 2:APT 3A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-1525
Mailing Address - Country:US
Mailing Address - Phone:718-513-4052
Mailing Address - Fax:
Practice Address - Street 1:105 KINGS HWY
Practice Address - Street 2:APT 3A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-1550
Practice Address - Country:US
Practice Address - Phone:718-332-1017
Practice Address - Fax:718-332-1354
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2016-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006615152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02351086Medicaid
NY02351086Medicaid
NYU93990Medicare UPIN