Healthcare Provider Details

I. General information

NPI: 1740100858
Provider Name (Legal Business Name): WILLIAMSBURG MEDICAL OF NEW YORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 BROADWAY STE 103
HEWLETT NY
11557-2014
US

IV. Provider business mailing address

PO BOX 32
NORTHBROOK IL
60065-0032
US

V. Phone/Fax

Practice location:
  • Phone: 847-257-1244
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. YAN KATSNELSON
Title or Position: CEO
Credential:
Phone: 847-774-5300