Provider Demographics
NPI:1962529586
Name:SURIKOV, VADIM (DO)
Entity type:Individual
Prefix:
First Name:VADIM
Middle Name:
Last Name:SURIKOV
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 1:5600 KENNEDY BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093
Mailing Address - Country:US
Mailing Address - Phone:201-866-3100
Mailing Address - Fax:
Practice Address - Street 1:5600 KENNEDY BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093
Practice Address - Country:US
Practice Address - Phone:201-866-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB075789002081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0076929Medicaid
NJ074298TMKMedicare PIN
NJ0076929Medicaid