Provider Demographics
NPI:1588670194
Name:KIZELSHTEYN, TATYANA
Entity Type:Individual
Prefix:DR
First Name:TATYANA
Middle Name:
Last Name:KIZELSHTEYN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2134 BARNES AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-1902
Mailing Address - Country:US
Mailing Address - Phone:718-828-3663
Mailing Address - Fax:718-828-3154
Practice Address - Street 1:2134 BARNES AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-1902
Practice Address - Country:US
Practice Address - Phone:718-828-3663
Practice Address - Fax:718-828-3154
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1714142080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01028160Medicaid
NY01028160Medicaid
NY07E691Medicare ID - Type Unspecified