Provider Demographics
NPI:1184667461
Name:KIZELSHTEYN, GRIGORY ISACC (MD)
Entity Type:Individual
Prefix:MR
First Name:GRIGORY
Middle Name:ISACC
Last Name:KIZELSHTEYN
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 1:220 WESTCHESTER AVENUE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10604
Mailing Address - Country:US
Mailing Address - Phone:914-289-1507
Mailing Address - Fax:914-289-0937
Practice Address - Street 1:220 WESTCHESTER AVENUE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10604
Practice Address - Country:US
Practice Address - Phone:914-289-1507
Practice Address - Fax:914-289-0937
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1661111207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01216375Medicaid
P1253384OtherOXFORD
91389OtherNY GOVERNMENT
NY7U8001Medicare PIN
A97613Medicare UPIN
91389OtherNY GOVERNMENT