Healthcare Provider Details

I. General information

NPI: 1316234669
Provider Name (Legal Business Name): SEA GATE MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1961 CONEY ISLAND AVE
BROOKLYN NY
11223-2328
US

IV. Provider business mailing address

2580 OCEAN PKWY APT. 2L
BROOKLYN NY
11235-7746
US

V. Phone/Fax

Practice location:
  • Phone: 718-344-7637
  • Fax: 718-490-1468
Mailing address:
  • Phone: 718-236-5077
  • Fax: 718-715-1437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number205927
License Number StateNY

VIII. Authorized Official

Name: VALENTIN PRIDATKO
Title or Position: DO
Credential: DO
Phone: 718-236-5077