Provider Demographics
NPI:1922183391
Name:TETROK, MIKHAIL (DO)
Entity Type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:
Last Name:TETROK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4290 BROADWAY STE 2S
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3732
Mailing Address - Country:US
Mailing Address - Phone:212-781-5075
Mailing Address - Fax:212-781-4823
Practice Address - Street 1:4290 BROADWAY STE 2S
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3732
Practice Address - Country:US
Practice Address - Phone:212-781-5075
Practice Address - Fax:212-781-4823
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NY331947Medicare PIN
G81904Medicare UPIN