Healthcare Provider Details

I. General information

NPI: 1831154301
Provider Name (Legal Business Name): SERGEI A SOBOLEVSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 COURT ST STE 101
BROOKLYN NY
11231-4091
US

IV. Provider business mailing address

40 E OAKDENE AVE UNIT A
PALISADES PARK NJ
07650-1630
US

V. Phone/Fax

Practice location:
  • Phone: 718-393-5559
  • Fax: 718-603-9469
Mailing address:
  • Phone: 646-267-3432
  • Fax: 718-603-9469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberC1140
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC1140
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberC1140
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number220183
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: