Provider Demographics
NPI:1386656361
Name:RAYKHMAN, VITALY (MD)
Entity Type:Individual
Prefix:DR
First Name:VITALY
Middle Name:
Last Name:RAYKHMAN
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 1:2632 E 14TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3916
Mailing Address - Country:US
Mailing Address - Phone:718-375-2100
Mailing Address - Fax:
Practice Address - Street 1:2632 E 14TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3916
Practice Address - Country:US
Practice Address - Phone:718-375-2100
Practice Address - Fax:800-349-4298
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY220650208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02544916Medicaid
NYG400001817Medicare PIN
NYH99440Medicare UPIN
NY34R641Medicare PIN
NYA400004820Medicare PIN