Provider Demographics
NPI: | 1841591989 |
---|---|
Name: | BORIS OVODENKO MD PC |
Entity Type: | Organization |
Organization Name: | BORIS OVODENKO MD PC |
Other - Org Name: | AMERICAN VISION GROUP |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | BORIS |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | OVODENKO |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 718-679-9449 |
Mailing Address - Street 1: | 2613 E 16TH ST |
Mailing Address - Street 2: | |
Mailing Address - City: | BROOKLYN |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 11235-3805 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 718-679-9449 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2613 E 16TH ST |
Practice Address - Street 2: | |
Practice Address - City: | BROOKLYN |
Practice Address - State: | NY |
Practice Address - Zip Code: | 11235-3805 |
Practice Address - Country: | US |
Practice Address - Phone: | 718-679-9449 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-11-05 |
Last Update Date: | 2010-11-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 235346 | 207W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Single Specialty |