Provider Demographics
NPI:1346398690
Name:MASHKEVICH, GRIGORIY (MD)
Entity Type:Individual
Prefix:
First Name:GRIGORIY
Middle Name:
Last Name:MASHKEVICH
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:PO BOX 2625
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-8925
Mailing Address - Country:US
Mailing Address - Phone:718-544-9300
Mailing Address - Fax:718-544-9301
Practice Address - Street 1:10812 72ND AVE STE 3
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7080
Practice Address - Country:US
Practice Address - Phone:718-544-9300
Practice Address - Fax:718-544-9301
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98950207Y00000X
NY236999207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A989500OtherMEDI-CAL PPIN#
CAI70717Medicare UPIN
CAWA98950BMedicare PIN