Provider Demographics
NPI:1558386409
Name:PORETSKAYA, LYUDMILA (MD)
Entity Type:Individual
Prefix:DR
First Name:LYUDMILA
Middle Name:
Last Name:PORETSKAYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2379 65TH STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204
Mailing Address - Country:US
Mailing Address - Phone:718-375-0392
Mailing Address - Fax:718-375-4324
Practice Address - Street 1:2379 65TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-4045
Practice Address - Country:US
Practice Address - Phone:718-375-0392
Practice Address - Fax:718-375-4324
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208817173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01883843Medicaid
NYG80056Medicare UPIN
NY01883843Medicaid