Provider Demographics
NPI:1619975224
Name:BENTSIANOV, SOFIA A (MD)
Entity Type:Individual
Prefix:DR
First Name:SOFIA
Middle Name:A
Last Name:BENTSIANOV
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 1:40 W BRIGHTON AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-4901
Mailing Address - Country:US
Mailing Address - Phone:718-743-0464
Mailing Address - Fax:718-996-1123
Practice Address - Street 1:40 W BRIGHTON AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-4901
Practice Address - Country:US
Practice Address - Phone:718-743-0464
Practice Address - Fax:718-996-1123
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163251207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP377941OtherOXFORD
NY00914127Medicaid
NY52D301Medicare ID - Type Unspecified
A63104Medicare UPIN