Healthcare Provider Details

I. General information

NPI: 1508644956
Provider Name (Legal Business Name): ROGER RUVINOV FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 OCEAN PKWY
BROOKLYN NY
11235-8374
US

IV. Provider business mailing address

1610 AVENUE P APT 5C
BROOKLYN NY
11229-1143
US

V. Phone/Fax

Practice location:
  • Phone: 718-314-3388
  • Fax:
Mailing address:
  • Phone: 718-314-3388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number352382
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: