Provider Demographics
NPI:1245509454
Name:ALLA SHUSTAROVICH MD PC
Entity type:Organization
Organization Name:ALLA SHUSTAROVICH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ALLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUSTAROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-332-7411
Mailing Address - Street 1:99 BRIGHTON 11 STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235
Mailing Address - Country:US
Mailing Address - Phone:718-332-7411
Mailing Address - Fax:718-332-7412
Practice Address - Street 1:99 BRIGHTON 11 STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235
Practice Address - Country:US
Practice Address - Phone:718-332-7411
Practice Address - Fax:718-332-7412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203553207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01665952Medicaid
NYG29842Medicare UPIN