Provider Demographics
NPI:1073684726
Name:GUTNIK, IGOR (MD)
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:GUTNIK
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 1:2873 VALERIE CT
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-4654
Mailing Address - Country:US
Mailing Address - Phone:516-578-1489
Mailing Address - Fax:516-992-0701
Practice Address - Street 1:49 OAKCREST AVE
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-1415
Practice Address - Country:US
Practice Address - Phone:516-578-1489
Practice Address - Fax:908-450-0280
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224819207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02315108Medicaid
NY0454AFMedicare ID - Type UnspecifiedGHI MEDICARE
NYH71979Medicare UPIN
NY02315108Medicaid