Healthcare Provider Details

I. General information

NPI: 1992126197
Provider Name (Legal Business Name): IRINA KOCHEROVA M.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2013
Last Update Date: 12/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 WILLOUGHBY ST
BROOKLYN NY
11201-5257
US

IV. Provider business mailing address

57 WILLOUGHBY ST
BROOKLYN NY
11201-5257
US

V. Phone/Fax

Practice location:
  • Phone: 718-522-2122
  • Fax: 718-522-6983
Mailing address:
  • Phone: 718-522-2122
  • Fax: 718-522-6983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1799302
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: