Provider Demographics
NPI:1821063041
Name:KSOVRELI, OLENA (MD)
Entity Type:Individual
Prefix:DR
First Name:OLENA
Middle Name:
Last Name:KSOVRELI
Suffix:
Gender:F
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:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0988
Mailing Address - Country:US
Mailing Address - Phone:631-444-0650
Mailing Address - Fax:631-638-4170
Practice Address - Street 1:HEALTH SCIENCES CTR
Practice Address - Street 2:STONY BROOK UNIVERSITY
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8160
Practice Address - Country:US
Practice Address - Phone:631-444-8478
Practice Address - Fax:631-444-7546
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221578207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT047041OtherCT LICENCE
NY221578OtherLICENSE
CTCSP 0044740OtherDEPT. OF CONSUMER PROTECTION
NY02177879Medicaid
NYBK7332365OtherNYS DEA
NY02177879Medicaid
NYH43449Medicare UPIN
CT047041OtherCT LICENCE