Provider Demographics
NPI:1962431841
Name:HEALTHY MEDICAL CARE
Entity type:Organization
Organization Name:HEALTHY MEDICAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NIKOLAI
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGODUKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-897-0300
Mailing Address - Street 1:9876 QUEENS BLVD
Mailing Address - Street 2:SUITE 1K
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4356
Mailing Address - Country:US
Mailing Address - Phone:718-897-0300
Mailing Address - Fax:718-897-3330
Practice Address - Street 1:9876 QUEENS BLVD
Practice Address - Street 2:SUITE 1K
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4356
Practice Address - Country:US
Practice Address - Phone:718-897-0300
Practice Address - Fax:718-897-3330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233906207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07255Medicare ID - Type Unspecified