Provider Demographics
NPI:1477708907
Name:VENGEROVICH, GENNADIY
Entity Type:Individual
Prefix:
First Name:GENNADIY
Middle Name:
Last Name:VENGEROVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15280 NW 79TH CT STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5873
Mailing Address - Country:US
Mailing Address - Phone:305-558-3724
Mailing Address - Fax:786-907-4485
Practice Address - Street 1:10150 HAGEN RANCH RD STE 100
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3776
Practice Address - Country:US
Practice Address - Phone:561-736-8141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME116592207YP0228X, 207YP0228X
NYME116592207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology