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General NPI Number Information
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NPI Number | 1841281540
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Entity Type | Individual
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Provider Name | BORIS A KONNIKOW MD PHD
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Gender | Male
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Dates
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Enumeration Date | 11/02/2005
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Last Update Date | 08/14/2013
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Provider Practice Location Address
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Address Line | 11020 71ST RD SUITE 104
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City | FOREST HILLS
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State | NY
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Zip | 11375-4945
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Country | US
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Telephone | 718-263-3355
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Fax | 718-263-3373
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Provider Business Mailing Address
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Address Line | 11020 71ST RD SUITE 104
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City | FOREST HILLS
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State | NY
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Zip | 11375-4914
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Country | US
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Telephone | 917-502-9888
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Fax | 718-263-3373
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 204106
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License Number State | NY
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