Healthcare Provider Details

I. General information

NPI: 1861413981
Provider Name (Legal Business Name): PETRYCHENKO PHYSICIAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 12/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 OCEAN AVE FL 6
BROOKLYN NY
11235-3202
US

IV. Provider business mailing address

2960 OCEAN AVE FL 6
BROOKLYN NY
11235-3202
US

V. Phone/Fax

Practice location:
  • Phone: 718-336-5123
  • Fax: 718-336-5137
Mailing address:
  • Phone: 718-336-5123
  • Fax: 718-336-5137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. DMITRI PETRYCHENKO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 718-336-5123