=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740293786
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELLORSO, GOUTOS, OLSHANETSKIY, PHYSICIANS LAGUARDIA, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | LAGUARDIA AIRPORT CENTRAL TERM BLDG SUITE 3771
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-424-8663
-----------------------------------------------------
Fax | 712-424-8664
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | LAGUARDIA AIRPORT CENTRAL TERMINAL BLDG SUITE 3771
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-424-8663
-----------------------------------------------------
Fax | 712-424-8664
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | OLEG OLSHANETSKIY
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 712-244-1644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------