Provider Demographics
NPI:1982754602
Name:NICKITA, MIKHAIL VLADIMIR (MD)
Entity Type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:VLADIMIR
Last Name:NICKITA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MYHALLO
Other - Middle Name:
Other - Last Name:NIKITIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:42 GRANDVIEW CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030
Mailing Address - Country:US
Mailing Address - Phone:212-730-7777
Mailing Address - Fax:212-730-7797
Practice Address - Street 1:1430 BROADWAY
Practice Address - Street 2:SUITE 1608
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018
Practice Address - Country:US
Practice Address - Phone:212-730-7777
Practice Address - Fax:212-730-7797
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2239572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02365433Medicaid
NY02365433Medicaid
H95198Medicare ID - Type Unspecified