Provider Demographics
NPI:1710950878
Name:NOVOFASTOVSKY, RAISA
Entity Type:Individual
Prefix:
First Name:RAISA
Middle Name:
Last Name:NOVOFASTOVSKY
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 1:1812 QUENTIN RD
Mailing Address - Street 2:SUITE M-2
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1336
Mailing Address - Country:US
Mailing Address - Phone:718-382-1773
Mailing Address - Fax:718-382-3214
Practice Address - Street 1:1812 QUENTIN RD
Practice Address - Street 2:SUITE M-2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1336
Practice Address - Country:US
Practice Address - Phone:718-382-1773
Practice Address - Fax:718-382-3214
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN 004903213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01250811Medicaid
NYP3603491OtherOXFORD
214483POtherHIP
NYP3603491OtherOXFORD
NY6720200001Medicare NSC