Healthcare Provider Details

I. General information

NPI: 1053430272
Provider Name (Legal Business Name): IGOR SINIAKOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 BROOKSTONE CENTRE PKWY
COLUMBUS GA
31904-9272
US

IV. Provider business mailing address

1210 BROOKSTONE CENTRE PKWY
COLUMBUS GA
31904-9272
US

V. Phone/Fax

Practice location:
  • Phone: 706-322-1717
  • Fax: 706-322-1718
Mailing address:
  • Phone: 706-322-1717
  • Fax: 706-322-1718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number79701
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number79701
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: