Provider Demographics
NPI:1538696372
Name:OMICRON MEDICAL PC
Entity Type:Organization
Organization Name:OMICRON MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURSHTEYN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-459-3494
Mailing Address - Street 1:10525 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1640
Mailing Address - Country:US
Mailing Address - Phone:718-459-3494
Mailing Address - Fax:718-606-6069
Practice Address - Street 1:10525 64TH AVE
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1640
Practice Address - Country:US
Practice Address - Phone:718-459-3494
Practice Address - Fax:718-606-6069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2156381207R00000X
NYN0060751213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty