Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1100X | Ophthalmic | 007005 | NY |
NPI | 1720225733 |
---|---|
Provider Name | Mr. Vadim Kruzhkov |
First Address | Brooklyn, NY 11222-2967 |
Second Address | Brooklyn, NY 11222-2967 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/01/2009 |
Last Update Date | 13/01/2009 |