Basic Information
| Provider Information | |||||||||
| NPI: | 1346398690 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASHKEVICH | ||||||||
| FirstName: | GRIGORIY | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2625 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100098925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185449300 | ||||||||
| FaxNumber: | 7185449301 | ||||||||
| Practice Location | |||||||||
| Address1: | 10812 72ND AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113757080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185449300 | ||||||||
| FaxNumber: | 7185449301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 09/12/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | A98950 | CA | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207YS0123X | 236999 | NY | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00A989500 | 01 | CA | MEDI-CAL PPIN# | OTHER |