Provider Demographics
NPI:1821202441
Name:KHISHCHENKO, NATAN (MD)
Entity Type:Individual
Prefix:
First Name:NATAN
Middle Name:
Last Name:KHISHCHENKO
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 1:2101 LAC DEVILLE BLVD.
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618
Mailing Address - Country:US
Mailing Address - Phone:585-546-3265
Mailing Address - Fax:585-232-5158
Practice Address - Street 1:2101 LAC DEVILLE BLVD.
Practice Address - Street 2:SUITE 1
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618
Practice Address - Country:US
Practice Address - Phone:585-546-3265
Practice Address - Fax:585-232-5158
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT909722084N0400X
NH207262084N0400X
NY2457452084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02909722Medicaid
NY02909722Medicaid
NYRB8434 / GRP 70008AMedicare PIN