Healthcare Provider Details

I. General information

NPI: 1447512793
Provider Name (Legal Business Name): IGOR LOBKOV SPED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 EXECUTIVE DR
PLAINVIEW NY
11803-1718
US

IV. Provider business mailing address

2954 W 8TH ST APT 20B
BROOKLYN NY
11224-3220
US

V. Phone/Fax

Practice location:
  • Phone: 516-576-0962
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number563143111
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number563144111
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: