Provider Demographics
NPI:1326101601
Name:MAMONTOV, MIKHAIL (MD)
Entity Type:Individual
Prefix:MR
First Name:MIKHAIL
Middle Name:
Last Name:MAMONTOV
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 1:2269 EAST 29TH STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229
Mailing Address - Country:US
Mailing Address - Phone:718-613-4000
Mailing Address - Fax:718-613-4896
Practice Address - Street 1:INTERFAITH MEDICAL CENTER
Practice Address - Street 2:1545 ATLANTIC AVE
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213
Practice Address - Country:US
Practice Address - Phone:718-613-4856
Practice Address - Fax:718-613-4896
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212531207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01946872Medicaid
NY86I971Medicare ID - Type Unspecified
NY01946872Medicaid