Healthcare Provider Details

I. General information

NPI: 1093891079
Provider Name (Legal Business Name): EVGENY OLENKO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10537 64TH AVE
FOREST HILLS NY
11375-1645
US

IV. Provider business mailing address

105-37 64 AVENUE
FOREST HILLS NY
11375-1645
US

V. Phone/Fax

Practice location:
  • Phone: 718-459-0111
  • Fax: 718-896-1596
Mailing address:
  • Phone: 718-459-0111
  • Fax: 718-896-1596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number145218
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number145218
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: