Healthcare Provider Details

I. General information

NPI: 1194657197
Provider Name (Legal Business Name): MARAT VIGDORCHIK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2516 WEST ST APT 2A
BROOKLYN NY
11223-6143
US

IV. Provider business mailing address

2516 WEST ST APT 2A
BROOKLYN NY
11223-6143
US

V. Phone/Fax

Practice location:
  • Phone: 718-473-7314
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2043553261
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: