Provider Demographics
NPI:1205867140
Name:KAGANOVSKY, ELINA
Entity Type:Individual
Prefix:
First Name:ELINA
Middle Name:
Last Name:KAGANOVSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-4604
Mailing Address - Country:US
Mailing Address - Phone:718-934-6777
Mailing Address - Fax:718-934-9560
Practice Address - Street 1:2700 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4604
Practice Address - Country:US
Practice Address - Phone:718-934-6777
Practice Address - Fax:718-934-9560
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163225207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00901859Medicaid
NY48D191Medicare ID - Type Unspecified
NY00901859Medicaid