Provider Demographics
NPI:1962810036
Name:VYSOTSKYY, TARAS
Entity type:Individual
Prefix:DR
First Name:TARAS
Middle Name:
Last Name:VYSOTSKYY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 RICHMOND BLVD
Mailing Address - Street 2:UNIT 2A
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-3622
Mailing Address - Country:US
Mailing Address - Phone:516-695-0112
Mailing Address - Fax:
Practice Address - Street 1:45 RICHMOND BLVD
Practice Address - Street 2:UNIT 2A
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-3622
Practice Address - Country:US
Practice Address - Phone:516-695-0112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-01
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005677213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005677Medicaid