Healthcare Provider Details

I. General information

NPI: 1619935673
Provider Name (Legal Business Name): ALEKSANDER FEOKTISTOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 CLARKSON AVE
BROOKLYN NY
11203
US

IV. Provider business mailing address

451 CLARKSON AVE
BROOKLYN NY
11203-2054
US

V. Phone/Fax

Practice location:
  • Phone: 508-308-0354
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number214849-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: