Provider Demographics
NPI:1639235591
Name:RAIKHERT, ELENA
Entity Type:Individual
Prefix:MS
First Name:ELENA
Middle Name:
Last Name:RAIKHERT
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 1:890 ARMSTRONG AVE
Mailing Address - Street 2:1-3
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-1249
Mailing Address - Country:US
Mailing Address - Phone:718-605-7592
Mailing Address - Fax:
Practice Address - Street 1:150 GREAVES LN STE D
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-2173
Practice Address - Country:US
Practice Address - Phone:718-948-1353
Practice Address - Fax:718-948-1353
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7918156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician