Provider Demographics
NPI:1093873499
Name:MOSOVICH, SERGE A (MD)
Entity Type:Individual
Prefix:MR
First Name:SERGE
Middle Name:A
Last Name:MOSOVICH
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 1:82 GREENE STREET
Mailing Address - Street 2:#4R
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-4385
Mailing Address - Country:US
Mailing Address - Phone:212-427-9162
Mailing Address - Fax:212-828-4781
Practice Address - Street 1:5 EAST 94 STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-1913
Practice Address - Country:US
Practice Address - Phone:212-427-9162
Practice Address - Fax:212-828-4781
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY138784-12084P0800X
NY1387842084P0800X
NJ25MA086502002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0S127OtherOXFORD ID
NY138784-1OtherNY STATE LISENCE
NY00405990Medicaid
NY0S127OtherOXFORD ID
NY00405990Medicaid