Provider Demographics
NPI:1184034183
Name:MEDICAL STATE OF QUEENS
Entity Type:Organization
Organization Name:MEDICAL STATE OF QUEENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:
Authorized Official - First Name:NIKOLAI
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGODUKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-554-1150
Mailing Address - Street 1:8544 66TH RD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-5212
Mailing Address - Country:US
Mailing Address - Phone:718-565-6050
Mailing Address - Fax:
Practice Address - Street 1:8544 66TH RD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-5212
Practice Address - Country:US
Practice Address - Phone:718-565-6050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-30
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233906173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty