Provider Demographics
NPI:1528405420
Name:KHELEMSKY, SERGE (DO)
Entity Type:Individual
Prefix:
First Name:SERGE
Middle Name:
Last Name:KHELEMSKY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 RIVER TER APT 3801
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10282-1127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2310 65TH ST STE 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-4089
Practice Address - Country:US
Practice Address - Phone:718-376-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2924392084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MB10140800OtherSTATE LICENSE
NY292439OtherSTATE LICENSE
NY05191319Medicaid