Provider Demographics
NPI:1235197252
Name:ITSKOVICH, BORIS (MD)
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:ITSKOVICH
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 1:2693 ARKANSAS DR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-6833
Mailing Address - Country:US
Mailing Address - Phone:718-373-0777
Mailing Address - Fax:718-373-8454
Practice Address - Street 1:2993 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-8302
Practice Address - Country:US
Practice Address - Phone:718-373-0777
Practice Address - Fax:718-373-8454
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207492207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP825169OtherOXFORD
NY01799137Medicaid
NY2599419OtherGHI
NYBKX072001OtherAMERICHOICE
NYP825169OtherOXFORD
NYG60164Medicare UPIN
NY69X292Medicare PIN