Provider Demographics
NPI:1033173471
Name:ARTAMONOV, MIKHAIL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MIKHAIL
Middle Name:J
Last Name:ARTAMONOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 E BROWN ST
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-9101
Mailing Address - Country:US
Mailing Address - Phone:570-872-9800
Mailing Address - Fax:570-872-9888
Practice Address - Street 1:701 SE 6TH AVE STE 203B
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33483-5186
Practice Address - Country:US
Practice Address - Phone:570-872-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2023-11-21
Deactivation Date:2019-09-13
Deactivation Code:
Reactivation Date:2019-09-25
Provider Licenses
StateLicense IDTaxonomies
PAMD484898208100000X, 2081P0301X, 2081P2900X, 207RA0401X
NY2500592081P2900X
FLME1008372081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P0301XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationBrain Injury Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011567330001Medicaid
NY03079009Medicaid
PAI18217Medicare UPIN
PAI18217Medicare UPIN