Provider Demographics
NPI:1588848444
Name:KINGS MEDICAL PC
Entity Type:Organization
Organization Name:KINGS MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ISAKOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-312-2052
Mailing Address - Street 1:3030 OCEAN AVE
Mailing Address - Street 2:#4F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3363
Mailing Address - Country:US
Mailing Address - Phone:347-312-2052
Mailing Address - Fax:
Practice Address - Street 1:1379 54TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-4259
Practice Address - Country:US
Practice Address - Phone:347-603-5647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238803208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02744714Medicaid
NY1655J1Medicare PIN
NYPENDINGMedicare PIN