Provider Demographics
NPI:1700849494
Name:PUSTYLNIKOV, RAISA (MD)
Entity Type:Individual
Prefix:DR
First Name:RAISA
Middle Name:
Last Name:PUSTYLNIKOV
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 1:1840 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-2800
Mailing Address - Country:US
Mailing Address - Phone:718-680-1600
Mailing Address - Fax:718-680-4473
Practice Address - Street 1:1840 E 14TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-2800
Practice Address - Country:US
Practice Address - Phone:718-680-1600
Practice Address - Fax:718-680-4473
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206096207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4985397OtherCIGNA PPO, HMO, EPO
NY4C6646OtherHEALTH NET(HMO)
NY857141OtherEMPIRE BC/BS
NY01733586Medicaid
NYBK00611 04OtherAMERICHOICE
NY102086OtherHERITAGE
NY11-3552139OtherPHCS
NY206096OtherHIP
NY13252OtherELDER PLAN
NY2595569OtherGHI
NYP2115470OtherOXFORD
NY11-3552139Other1199 NBF
NY2422571OtherAETNA HMO
NY857141OtherEMPIRE BC/BS
NY01733586Medicaid