Provider Demographics
NPI:1508838442
Name:KANOV, LUBOMIR M (MD)
Entity Type:Individual
Prefix:
First Name:LUBOMIR
Middle Name:M
Last Name:KANOV
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 1:119 N PARK AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-4113
Mailing Address - Country:US
Mailing Address - Phone:516-764-5574
Mailing Address - Fax:516-594-4053
Practice Address - Street 1:119 N PARK AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4113
Practice Address - Country:US
Practice Address - Phone:516-764-5574
Practice Address - Fax:516-594-4053
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-04
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1807322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01256808Medicaid
NY01256808Medicaid
NYE87425Medicare UPIN