Healthcare Provider Details

I. General information

NPI: 1831658699
Provider Name (Legal Business Name): ILYA NOGINSKIY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 04/19/2026
Certification Date: 04/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 POMFRET ST
PUTNAM CT
06260-1869
US

IV. Provider business mailing address

2524 AVENUE Y
BROOKLYN NY
11235-2423
US

V. Phone/Fax

Practice location:
  • Phone: 860-928-6541
  • Fax:
Mailing address:
  • Phone: 718-780-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number17699C
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number71669
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25MA11798600
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number13005727-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: