Provider Demographics
NPI:1780063222
Name:BENTSIANOV, EUGENE
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:BENTSIANOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 KNAPP ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-5924
Mailing Address - Country:US
Mailing Address - Phone:718-513-0409
Mailing Address - Fax:
Practice Address - Street 1:2310 KNAPP ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-5924
Practice Address - Country:US
Practice Address - Phone:718-513-0409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060148183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist