Provider Demographics
NPI:1346552338
Name:TARASCIN, ILYA (DO)
Entity Type:Individual
Prefix:DR
First Name:ILYA
Middle Name:
Last Name:TARASCIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 STEWART AVENUE
Mailing Address - Street 2:SUITE 300, LONG ISLAND FQHC, INC.
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590
Mailing Address - Country:US
Mailing Address - Phone:516-571-8200
Mailing Address - Fax:
Practice Address - Street 1:161 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-1432
Practice Address - Country:US
Practice Address - Phone:516-571-8200
Practice Address - Fax:516-571-8221
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY269210207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine