Provider Demographics
NPI:1003871179
Name:KOTELSKIY, OLEG (DO)
Entity Type:Individual
Prefix:
First Name:OLEG
Middle Name:
Last Name:KOTELSKIY
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 1:3816 NOSTRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-2013
Mailing Address - Country:US
Mailing Address - Phone:718-338-2323
Mailing Address - Fax:718-338-7117
Practice Address - Street 1:3816 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-2013
Practice Address - Country:US
Practice Address - Phone:718-338-2323
Practice Address - Fax:718-338-7117
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2050591207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01749417Medicaid
NY2050591OtherLICENSE NUMBER
NY2050591OtherLICENSE NUMBER
NY01749417Medicaid