Provider Demographics
NPI:1982679023
Name:OSIPOVA, LADA (DO)
Entity Type:Individual
Prefix:DR
First Name:LADA
Middle Name:
Last Name:OSIPOVA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795
Mailing Address - Country:US
Mailing Address - Phone:631-321-1286
Mailing Address - Fax:631-321-1379
Practice Address - Street 1:747 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795
Practice Address - Country:US
Practice Address - Phone:631-321-1286
Practice Address - Fax:631-321-1379
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215517207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02160025Medicaid
NY50V291OtherBLUE CROSS
H31357Medicare UPIN
NY02160025Medicaid