Provider Demographics
NPI:1932369816
Name:KHAITOV, SERGEY (MD)
Entity Type:Individual
Prefix:
First Name:SERGEY
Middle Name:
Last Name:KHAITOV
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 1:5 E 98TH ST, 15TH FL
Mailing Address - Street 2:BOX 1259
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6501
Mailing Address - Country:US
Mailing Address - Phone:212-241-1763
Mailing Address - Fax:212-241-5975
Practice Address - Street 1:5 E 98TH ST, 14TH FL
Practice Address - Street 2:SUITE C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6501
Practice Address - Country:US
Practice Address - Phone:212-241-1763
Practice Address - Fax:212-241-5975
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-13
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY235880208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400012333Medicare PIN