Provider Demographics
NPI:1972754109
Name:KOVBASYUK, ALEXANDER (ETC)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:KOVBASYUK
Suffix:
Gender:M
Credentials:ETC
Other - Prefix:
Other - First Name:ALEXANDER
Other - Middle Name:
Other - Last Name:KOVBASYUK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3065 BRIGHTON 14ST
Mailing Address - Street 2:LOWER LEWEL
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-5501
Mailing Address - Country:US
Mailing Address - Phone:718-332-5047
Mailing Address - Fax:
Practice Address - Street 1:3065 BRIGHTON 14ST
Practice Address - Street 2:LOWER LEWEL
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5501
Practice Address - Country:US
Practice Address - Phone:718-332-5047
Practice Address - Fax:631-576-0540
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006560-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician