Provider Demographics
NPI:1477627370
Name:STANISLAV KULISHOV PHYSICIAN P.C.
Entity Type:Organization
Organization Name:STANISLAV KULISHOV PHYSICIAN P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STANISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KULISHOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-627-3939
Mailing Address - Street 1:1833 E 13TH ST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-2807
Mailing Address - Country:US
Mailing Address - Phone:718-627-3939
Mailing Address - Fax:718-627-8737
Practice Address - Street 1:1833 E 13TH ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-2807
Practice Address - Country:US
Practice Address - Phone:718-627-3939
Practice Address - Fax:718-627-8737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2089482084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03475514Medicaid
NYG66731Medicare UPIN
NY03475514Medicaid