Provider Demographics
NPI:1811255003
Name:MEYTES, VADIM (DO)
Entity type:Individual
Prefix:DR
First Name:VADIM
Middle Name:
Last Name:MEYTES
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 1:110 BENNETT AVE
Mailing Address - Street 2:APT 2F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-2308
Mailing Address - Country:US
Mailing Address - Phone:212-444-2804
Mailing Address - Fax:
Practice Address - Street 1:21 READE PL STE 3100
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601
Practice Address - Country:US
Practice Address - Phone:845-214-1800
Practice Address - Fax:845-214-1818
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2894402086S0127X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04793073Medicaid