Provider Demographics
NPI:1417994922
Name:ITZKOVITZ, INA (MD)
Entity Type:Individual
Prefix:
First Name:INA
Middle Name:
Last Name:ITZKOVITZ
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 1:441 9TH AVE
Mailing Address - Street 2:ACP-CREDENTIALING
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-1623
Mailing Address - Country:US
Mailing Address - Phone:646-680-2894
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:355 W 52ND ST FL 7
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-6239
Practice Address - Country:US
Practice Address - Phone:646-754-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154575207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01027256Medicaid
NY03E437Z761OtherMEDICARE-ACP
NYE36601Medicare UPIN