Provider Demographics
NPI:1407002702
Name:LONDON MEDICAL DIAGNOSTIC PC
Entity Type:Organization
Organization Name:LONDON MEDICAL DIAGNOSTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:BURSHTEYN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-459-3494
Mailing Address - Street 1:10525 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1640
Mailing Address - Country:US
Mailing Address - Phone:718-459-3494
Mailing Address - Fax:718-606-6069
Practice Address - Street 1:10525 64TH AVE
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1640
Practice Address - Country:US
Practice Address - Phone:718-459-3494
Practice Address - Fax:718-606-6069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215638174400000X
174400000X, 207R00000X, 213E00000X, 225100000X, 363AM0700X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03272777Medicaid