Healthcare Provider Details

I. General information

NPI: 1003871179
Provider Name (Legal Business Name): OLEG KOTELSKIY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3816 NOSTRAND AVE
BROOKLYN NY
11235-2013
US

IV. Provider business mailing address

3816 NOSTRAND AVE
BROOKLYN NY
11235-2013
US

V. Phone/Fax

Practice location:
  • Phone: 718-338-2323
  • Fax: 718-338-7117
Mailing address:
  • Phone: 718-338-2323
  • Fax: 718-338-7117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2050591
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: