Healthcare Provider Details

I. General information

NPI: 1962661538
Provider Name (Legal Business Name): ANDREY KOLESNIKOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

586 MIDLAND AVE STE 1B
STATEN ISLAND NY
10306-5901
US

IV. Provider business mailing address

586 MIDLAND AVE STE 1B
STATEN ISLAND NY
10306-5901
US

V. Phone/Fax

Practice location:
  • Phone: 465-987-7916
  • Fax: 646-437-5457
Mailing address:
  • Phone: 465-987-7916
  • Fax: 646-437-5457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number287701
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: