Healthcare Provider Details

I. General information

NPI: 1558507178
Provider Name (Legal Business Name): PETR LEONIDOVICH TSENOVOY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2009
Last Update Date: 08/19/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 MOHAWK AVE
NORWOOD NJ
07648-2410
US

IV. Provider business mailing address

95 GRASSLANDS RD NEW YORK MED COLLEGE, MUNGER PAVILION, ROOM 253
VALHALLA NY
10595-1652
US

V. Phone/Fax

Practice location:
  • Phone: 201-392-3588
  • Fax:
Mailing address:
  • Phone: 914-493-8373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25MA09126700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number25MA09126700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: