Provider Demographics
NPI:1760572903
Name:MEDVED, VLADIMIR
Entity Type:Individual
Prefix:
First Name:VLADIMIR
Middle Name:
Last Name:MEDVED
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 1:24 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-1350
Mailing Address - Country:US
Mailing Address - Phone:518-481-6044
Mailing Address - Fax:518-481-6043
Practice Address - Street 1:24 4TH ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1350
Practice Address - Country:US
Practice Address - Phone:518-481-6044
Practice Address - Fax:518-481-6043
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221956207Q00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02410126Medicaid
NY5996910OtherGHI FAMILY HEALTH PLUS
NY364145OtherMVP HEALTH PLAN
NYP010221956OtherBLUE CROSS/BLUE SHIELD
NYP00189181OtherRAILROAD MEDICARE
NY02410126Medicaid
NY5996910OtherGHI FAMILY HEALTH PLUS