Provider Demographics
NPI:1841281540
Name:KONNIKOW, BORIS A (MD PHD)
Entity type:Individual
Prefix:
First Name:BORIS
Middle Name:A
Last Name:KONNIKOW
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11020 71ST RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4914
Mailing Address - Country:US
Mailing Address - Phone:917-502-9888
Mailing Address - Fax:718-263-3373
Practice Address - Street 1:11020 71ST RD
Practice Address - Street 2:SUITE 104
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4945
Practice Address - Country:US
Practice Address - Phone:718-263-3355
Practice Address - Fax:718-263-3373
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2041062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02101206Medicaid
NY02101206Medicaid
053M1010Medicare UPIN