Provider Demographics
NPI:1780631804
Name:SERGEYEV, IGOR (MD)
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:SERGEYEV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9101 4TH AVE
Mailing Address - Street 2:STE 2F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-6368
Mailing Address - Country:US
Mailing Address - Phone:718-680-0265
Mailing Address - Fax:718-680-0036
Practice Address - Street 1:9101 4TH AVE
Practice Address - Street 2:STE 2F
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-6368
Practice Address - Country:US
Practice Address - Phone:718-680-0265
Practice Address - Fax:718-680-0036
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228019208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY228019-1OtherNY STATE LICENSE NUMBER
NY02760272Medicaid
NYA400102953Medicare PIN
NYA100102920Medicare PIN
NY4S5011Medicare PIN