Provider Demographics
NPI:1205058542
Name:PODDOUBNAIA, TATIANA V (LAC)
Entity type:Individual
Prefix:MS
First Name:TATIANA
Middle Name:V
Last Name:PODDOUBNAIA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 12TH ST
Mailing Address - Street 2:B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3919
Mailing Address - Country:US
Mailing Address - Phone:646-505-7000
Mailing Address - Fax:
Practice Address - Street 1:150 BROADWAY
Practice Address - Street 2:SUITE 1012
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-4381
Practice Address - Country:US
Practice Address - Phone:212-233-3255
Practice Address - Fax:212-233-3246
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003178171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist