Healthcare Provider Details

I. General information

NPI: 1861735656
Provider Name (Legal Business Name): LIUDMILA A SKUDNOV DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 TARGEE ST APT 4T
STATEN ISLAND NY
10304-4472
US

IV. Provider business mailing address

1000 TARGEE ST APT 4T
STATEN ISLAND NY
10304-4472
US

V. Phone/Fax

Practice location:
  • Phone: 917-349-0933
  • Fax:
Mailing address:
  • Phone: 917-349-0933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2868871
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number286887
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: