Healthcare Provider Details

I. General information

NPI: 1306876602
Provider Name (Legal Business Name): KONSTANTIN PERTSOVSKY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 HAMBURG TPKE WAYNE COMMONS, SUITE 101
WAYNE NJ
07470-2025
US

IV. Provider business mailing address

414 LAFAYETTE AVE APT.A
CLIFFSIDE PARK NJ
07010-2024
US

V. Phone/Fax

Practice location:
  • Phone: 973-942-6005
  • Fax: 973-942-6009
Mailing address:
  • Phone: 201-840-4081
  • Fax: 201-840-4081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MB07552900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number214845
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number214845
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: