Healthcare Provider Details

I. General information

NPI: 1346552338
Provider Name (Legal Business Name): ILYA TARASCIN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 HEMPSTEAD TPKE
ELMONT NY
11003-1432
US

IV. Provider business mailing address

1600 STEWART AVENUE SUITE 300, LONG ISLAND FQHC, INC.
WESTBURY NY
11590
US

V. Phone/Fax

Practice location:
  • Phone: 516-571-8200
  • Fax: 516-571-8221
Mailing address:
  • Phone: 516-571-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number269210
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: