Provider Demographics
NPI:1073893178
Name:ODINTSOV, PAVEL (APN)
Entity Type:Individual
Prefix:MR
First Name:PAVEL
Middle Name:
Last Name:ODINTSOV
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 GRAND ST
Mailing Address - Street 2:3RD FL
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1035
Mailing Address - Country:US
Mailing Address - Phone:845-987-3906
Mailing Address - Fax:845-987-5979
Practice Address - Street 1:10 FRANKLIN TPKE
Practice Address - Street 2:
Practice Address - City:MAHWAH
Practice Address - State:NJ
Practice Address - Zip Code:07430-1304
Practice Address - Country:US
Practice Address - Phone:201-529-0033
Practice Address - Fax:201-529-5913
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306748363LA2200X
NJ26NJ00337800363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health