Provider Demographics
NPI:1356315527
Name:SHUSTAROVICH, ALLA (MD)
Entity Type:Individual
Prefix:
First Name:ALLA
Middle Name:
Last Name:SHUSTAROVICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 W END AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-4904
Mailing Address - Country:US
Mailing Address - Phone:718-934-3636
Mailing Address - Fax:
Practice Address - Street 1:99 BRIGHTON 11 STR
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235
Practice Address - Country:US
Practice Address - Phone:718-332-7411
Practice Address - Fax:718-332-7412
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203553207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01665952Medicaid
NY01665952Medicaid
NY763081Medicare ID - Type Unspecified