Provider Demographics
NPI:1497857502
Name:KULISHOV, STANISLAV (MD)
Entity Type:Individual
Prefix:DR
First Name:STANISLAV
Middle Name:
Last Name:KULISHOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 EAST 13 STREET
Mailing Address - Street 2:STE 1A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229
Mailing Address - Country:US
Mailing Address - Phone:718-627-3939
Mailing Address - Fax:718-627-8737
Practice Address - Street 1:1833 EAST 13 STREET
Practice Address - Street 2:STE 1A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229
Practice Address - Country:US
Practice Address - Phone:718-627-3939
Practice Address - Fax:718-627-8737
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2089482084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01817945Medicaid
NY364N21Medicare ID - Type Unspecified
G66731Medicare UPIN