Healthcare Provider Details

I. General information

NPI: 1902872963
Provider Name (Legal Business Name): CHAIM SHTOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 GRAVESEND NECK RD
BROOKLYN NY
11223-5126
US

IV. Provider business mailing address

1880 E 4TH ST APT B14
BROOKLYN NY
11223-2834
US

V. Phone/Fax

Practice location:
  • Phone: 718-382-6669
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number221006
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: