Provider Demographics
NPI:1164541165
Name:RIVKIN, OLEG (PA-C)
Entity Type:Individual
Prefix:
First Name:OLEG
Middle Name:
Last Name:RIVKIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 KINDERKAMACK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ORADELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07649-1600
Mailing Address - Country:US
Mailing Address - Phone:201-741-2550
Mailing Address - Fax:201-342-7171
Practice Address - Street 1:680 KINDERKAMACK RD
Practice Address - Street 2:SUITE 300
Practice Address - City:ORADELL
Practice Address - State:NJ
Practice Address - Zip Code:07649-1600
Practice Address - Country:US
Practice Address - Phone:201-741-2550
Practice Address - Fax:201-342-7171
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009405363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6039L1Medicare ID - Type Unspecified
NYQ57395Medicare UPIN