Basic Information
| Provider Information | |||||||||
| NPI: | 1285861682 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OCEAN MEDICAL PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2792 OCEAN AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112294708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187437090 | ||||||||
| FaxNumber: | 7186481328 | ||||||||
| Practice Location | |||||||||
| Address1: | 2792 OCEAN AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112294708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187437090 | ||||||||
| FaxNumber: | 7186481328 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2009 | ||||||||
| LastUpdateDate: | 06/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | ZAVELYUK | ||||||||
| AuthorizedOfficialFirstName: | STELLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7187437090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 03140269 | 05 | NY | MEDICAID |