Provider Demographics
NPI:1659471944
Name:GRIBENKO, VIKTOR (MD)
Entity Type:Individual
Prefix:
First Name:VIKTOR
Middle Name:
Last Name:GRIBENKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9964 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-7936
Mailing Address - Country:US
Mailing Address - Phone:718-748-8193
Mailing Address - Fax:718-946-7964
Practice Address - Street 1:170 AVENUE S
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-2633
Practice Address - Country:US
Practice Address - Phone:718-946-7967
Practice Address - Fax:718-946-7964
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211122208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01933513Medicaid
NY01933513Medicaid
G24895Medicare UPIN