Provider Demographics
NPI:1467752865
Name:GONCHAROV, ALEKSANDR (PT)
Entity Type:Individual
Prefix:
First Name:ALEKSANDR
Middle Name:
Last Name:GONCHAROV
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 OCEAN AVE APT 1D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-3928
Mailing Address - Country:US
Mailing Address - Phone:347-784-4530
Mailing Address - Fax:347-673-7904
Practice Address - Street 1:1702 AVENUE Z APT 5B
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3657
Practice Address - Country:US
Practice Address - Phone:347-784-4530
Practice Address - Fax:347-673-7904
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-01
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33232225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist