Provider Demographics
NPI:1619032539
Name:KHARITONOVA, ANNA A (DO)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:A
Last Name:KHARITONOVA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 82 STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209
Mailing Address - Country:US
Mailing Address - Phone:718-238-2285
Mailing Address - Fax:718-332-7412
Practice Address - Street 1:99 BRIGHTON 11 STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235
Practice Address - Country:US
Practice Address - Phone:718-238-2285
Practice Address - Fax:718-332-7412
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2089422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01911522Medicaid
NY01911522Medicaid
NY417R52Medicare ID - Type Unspecified
NYG86603Medicare UPIN