Healthcare Provider Details

I. General information

NPI: 1992124416
Provider Name (Legal Business Name): GRIGORIY GUTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2014
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 10TH AVENUE MAIMONIDES MEDICAL CENTER
BROOKLYN NY
11219
US

IV. Provider business mailing address

4802 10TH AVENUE MAIMONIDES MEDICAL CENTER
BROOKLYN NY
11219
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-6879
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number294177
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number294177
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: