Provider Demographics
NPI:1740293786
Name:DELLORSO, GOUTOS, OLSHANETSKIY, PHYSICIANS LAGUARDIA, PLLC
Entity type:Organization
Organization Name:DELLORSO, GOUTOS, OLSHANETSKIY, PHYSICIANS LAGUARDIA, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSHANETSKIY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:712-244-1644
Mailing Address - Street 1:LAGUARDIA AIRPORT CENTRAL TERMINAL BLDG
Mailing Address - Street 2:SUITE 3771
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11371
Mailing Address - Country:US
Mailing Address - Phone:718-424-8663
Mailing Address - Fax:712-424-8664
Practice Address - Street 1:LAGUARDIA AIRPORT CENTRAL TERM BLDG
Practice Address - Street 2:SUITE 3771
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11371
Practice Address - Country:US
Practice Address - Phone:718-424-8663
Practice Address - Fax:712-424-8664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty