Provider Demographics
NPI:1093768681
Name:KOUKHARENKO, IRINA (MD)
Entity Type:Individual
Prefix:MS
First Name:IRINA
Middle Name:
Last Name:KOUKHARENKO
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 1:2952 BRIGHTON 3RD ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-7078
Mailing Address - Country:US
Mailing Address - Phone:718-975-4334
Mailing Address - Fax:718-975-4337
Practice Address - Street 1:474 OVINGTON AVE
Practice Address - Street 2:LOWER LVEL
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-1550
Practice Address - Country:US
Practice Address - Phone:718-238-2625
Practice Address - Fax:718-238-2704
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232682207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02634619Medicaid
NYI20755Medicare UPIN
NY07286Medicare ID - Type UnspecifiedGHI MEDICARE
NY244AN1Medicare ID - Type UnspecifiedEMPIRE MEDICARE