Provider Demographics
NPI:1508907510
Name:OLEG KOTELSKIY D.O., P.C.
Entity Type:Organization
Organization Name:OLEG KOTELSKIY D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTELSKIY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:347-713-6871
Mailing Address - Street 1:3816 NOSTRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-2013
Mailing Address - Country:US
Mailing Address - Phone:347-713-6871
Mailing Address - Fax:347-713-6946
Practice Address - Street 1:3816 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-2013
Practice Address - Country:US
Practice Address - Phone:347-713-6871
Practice Address - Fax:347-713-6946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2050591207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2050591OtherLICENSE NUMBER
NYG44763Medicare UPIN