Provider Demographics
NPI:1891330023
Name:HENRICUS, MARSIYANA MISTIKA (MD)
Entity Type:Individual
Prefix:
First Name:MARSIYANA
Middle Name:MISTIKA
Last Name:HENRICUS
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 1:150 55TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-2508
Mailing Address - Country:US
Mailing Address - Phone:718-630-7000
Mailing Address - Fax:718-630-8515
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2508
Practice Address - Country:US
Practice Address - Phone:718-630-7000
Practice Address - Fax:718-630-8515
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320405208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist