Healthcare Provider Details

I. General information

NPI: 1225134869
Provider Name (Legal Business Name): BROOKLYN MEDICAL ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 OCEAN AVE
BROOKLYN NY
11230-6801
US

IV. Provider business mailing address

1915 OCEAN AVE
BROOKLYN NY
11230-6801
US

V. Phone/Fax

Practice location:
  • Phone: 718-951-0333
  • Fax: 718-951-3774
Mailing address:
  • Phone: 718-951-0333
  • Fax: 718-951-3774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number214274
License Number StateNY

VIII. Authorized Official

Name: DR. OLGA ALEXANDROVNA DIOUKALOVA
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 718-951-0333