Provider Demographics
NPI:1740295278
Name:KALITENKO, SERGEY
Entity type:Individual
Prefix:
First Name:SERGEY
Middle Name:
Last Name:KALITENKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10710 SHORE FRONT PKWY
Mailing Address - Street 2:APT. 10F
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-2637
Mailing Address - Country:US
Mailing Address - Phone:718-382-9200
Mailing Address - Fax:
Practice Address - Street 1:8295 N MILITARY TRL
Practice Address - Street 2:STE G
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33410-6312
Practice Address - Country:US
Practice Address - Phone:718-382-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211326-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01884413Medicaid
NY01884413Medicaid
NYG81194Medicare UPIN