Provider Demographics
NPI:1831154301
Name:SOBOLEVSKY, SERGEI A (MD)
Entity type:Individual
Prefix:
First Name:SERGEI
Middle Name:A
Last Name:SOBOLEVSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 E OAKDENE AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1630
Mailing Address - Country:US
Mailing Address - Phone:646-267-3432
Mailing Address - Fax:718-603-9469
Practice Address - Street 1:480 COURT ST STE 101
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11231-4091
Practice Address - Country:US
Practice Address - Phone:718-393-5559
Practice Address - Fax:718-603-9469
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYC11402085N0904X, 2085R0202X, 2085R0204X
NY2201832085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300090853Medicaid
KYK0014786OtherMEDICARE
NY02800351Medicaid