Healthcare Provider Details

I. General information

NPI: 1760504914
Provider Name (Legal Business Name): KONSTANTIN VATRENKO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 NORTH STREET EMERGENCY MEDICINE
PITTSFIELD MA
01201
US

IV. Provider business mailing address

725 NORTH STREET EMERGENCY MEDICINE
PITTSFIELD MA
01201
US

V. Phone/Fax

Practice location:
  • Phone: 413-395-7572
  • Fax:
Mailing address:
  • Phone: 413-395-7572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number270099
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: