Healthcare Provider Details

I. General information

NPI: 1275465585
Provider Name (Legal Business Name): VADIM PERTSOVSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2569 OCEAN AVE
BROOKLYN NY
11229-4576
US

IV. Provider business mailing address

259 DOVER ST
BROOKLYN NY
11235-3721
US

V. Phone/Fax

Practice location:
  • Phone: 718-332-3100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number408608
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: