Provider Demographics
NPI:1356424378
Name:VIKTOR GRIBENKO MD PC
Entity type:Organization
Organization Name:VIKTOR GRIBENKO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIKTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIBENKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-946-7967
Mailing Address - Street 1:9964 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-7936
Mailing Address - Country:US
Mailing Address - Phone:718-946-7967
Mailing Address - Fax:718-946-7964
Practice Address - Street 1:170 AVENUE S
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-2633
Practice Address - Country:US
Practice Address - Phone:718-946-7967
Practice Address - Fax:718-946-7964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW81711OtherMEDICARE PROVIDER NUMBER
NY01933513Medicaid
NY01933513Medicaid