Provider Demographics
NPI:1962408880
Name:MEDVEDOVSKY, MIHAIL (MD)
Entity type:Individual
Prefix:
First Name:MIHAIL
Middle Name:
Last Name:MEDVEDOVSKY
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 1:3039 OCEAN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-8370
Mailing Address - Country:US
Mailing Address - Phone:718-946-9070
Mailing Address - Fax:718-946-6375
Practice Address - Street 1:3039 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-8370
Practice Address - Country:US
Practice Address - Phone:718-946-9070
Practice Address - Fax:718-946-6375
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2014-12-10
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-06-02
Provider Licenses
StateLicense IDTaxonomies
NY180598207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYKP285OtherOXFORD
NYH4334459NOtherCIGNA MEDICARE, HMO
NY00000081512OtherBETTER HEALTH
NY01150765Medicaid
NYE62710Medicare UPIN
NY01150765Medicaid