Provider Demographics
NPI:1770627713
Name:GRINCHENKO, TATYANA (DO)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:GRINCHENKO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 STURBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-1562
Mailing Address - Country:US
Mailing Address - Phone:917-449-6890
Mailing Address - Fax:888-502-1596
Practice Address - Street 1:506 HAMBURG TPKE STE 201
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2069
Practice Address - Country:US
Practice Address - Phone:201-282-8356
Practice Address - Fax:888-502-1596
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY235641207RR0500X
NJMB082529207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0149781Medicaid
NJ116000VJ6Medicare PIN