Healthcare Provider Details

I. General information

NPI: 1851678692
Provider Name (Legal Business Name): VITAL MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2011
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1599 E 15TH ST
BROOKLYN NY
11230-6759
US

IV. Provider business mailing address

2812 E 28TH ST
BROOKLYN NY
11235-2204
US

V. Phone/Fax

Practice location:
  • Phone: 718-676-1743
  • Fax: 718-676-1746
Mailing address:
  • Phone: 718-676-1743
  • Fax: 718-676-1746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. DMITRY KONSKY
Title or Position: PRESIDENT
Credential: D.O.
Phone: 718-676-1743