Provider Demographics
NPI:1407246499
Name:DOKTOR, VLADYSLAVA (DO)
Entity Type:Individual
Prefix:
First Name:VLADYSLAVA
Middle Name:
Last Name:DOKTOR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 BEACH 19TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-4423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:256 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-6850
Practice Address - Country:US
Practice Address - Phone:857-219-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY284427207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program