Healthcare Provider Details

I. General information

NPI: 1245296607
Provider Name (Legal Business Name): IRINA MIKOLAENKO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 1ST AVE
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

3131 PRINCETON PIKE BLDG 5 SUITE 208
LAWRENCEVILLE NJ
08648
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-2269
  • Fax: 212-263-7916
Mailing address:
  • Phone: 609-815-7829
  • Fax: 609-815-7894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number40998
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number35088734
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number248672
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: