Healthcare Provider Details

I. General information

NPI: 1346398690
Provider Name (Legal Business Name): GRIGORIY MASHKEVICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10812 72ND AVE STE 3
FOREST HILLS NY
11375-7080
US

IV. Provider business mailing address

PO BOX 2625
NEW YORK NY
10009-8925
US

V. Phone/Fax

Practice location:
  • Phone: 718-544-9300
  • Fax: 718-544-9301
Mailing address:
  • Phone: 718-544-9300
  • Fax: 718-544-9301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA98950
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number236999
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: