Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | X009246 | NY |
Y | 111NI0013X | Independent Medical Examiner | X009246 | NY |
NPI | 1750579538 |
---|---|
Provider Name | Diana Vavikova |
First Address | New York, NY 10038 |
Second Address | New York, NY 10038-3563 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/10/2007 |
Last Update Date | 12/12/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
X009246 | LISCENSCE (01) | NY |