Provider Demographics
NPI:1124036835
Name:BORISOV, OLEG (DC)
Entity Type:Individual
Prefix:
First Name:OLEG
Middle Name:
Last Name:BORISOV
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 PENNSYLVANIA AVE
Mailing Address - Street 2:#7C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11239-1915
Mailing Address - Country:US
Mailing Address - Phone:718-368-0100
Mailing Address - Fax:718-368-1208
Practice Address - Street 1:126 BRIGHTON 11TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5327
Practice Address - Country:US
Practice Address - Phone:718-368-0100
Practice Address - Fax:718-368-1208
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010697-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX6T951Medicare PIN