Healthcare Provider Details

I. General information

NPI: 1699726315
Provider Name (Legal Business Name): ADVANCED WOUND CARE MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 AVENUE U
BROOKLYN NY
11223-4011
US

IV. Provider business mailing address

454 AVENUE U
BROOKLYN NY
11223-4011
US

V. Phone/Fax

Practice location:
  • Phone: 718-382-3400
  • Fax: 718-382-3420
Mailing address:
  • Phone: 718-382-3400
  • Fax: 718-382-3420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number218265
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number150869
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number087860
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number227059
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number156598
License Number StateNY

VIII. Authorized Official

Name: DR. SERGEI KOCHLATYI
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 718-382-3400