Provider Demographics
NPI:1023470093
Name:FEDOSSEEV, VLADIMIR (PT, DPT)
Entity type:Individual
Prefix:
First Name:VLADIMIR
Middle Name:
Last Name:FEDOSSEEV
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3371 RICHMOND AVE LOWR LEVEL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-2025
Mailing Address - Country:US
Mailing Address - Phone:718-808-9337
Mailing Address - Fax:347-983-6126
Practice Address - Street 1:3371 RICHMOND AVE LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-2025
Practice Address - Country:US
Practice Address - Phone:718-808-9337
Practice Address - Fax:347-983-6126
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038352-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist