Provider Demographics
NPI:1053495390
Name:KHODOSH, ZINAIDA (MD)
Entity Type:Individual
Prefix:DR
First Name:ZINAIDA
Middle Name:
Last Name:KHODOSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 OLIVER ST
Mailing Address - Street 2:APT. #4J
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-6568
Mailing Address - Country:US
Mailing Address - Phone:718-492-4832
Mailing Address - Fax:
Practice Address - Street 1:8415 4TH AVE
Practice Address - Street 2:APT.#A2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-4654
Practice Address - Country:US
Practice Address - Phone:718-332-7775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219695207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02107739Medicaid
NYH28623Medicare UPIN
NY862421Medicare ID - Type Unspecified