Basic Information
| Provider Information | |||||||||
| NPI: | 1578143095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLUSEK | ||||||||
| FirstName: | MALWINA | ||||||||
| MiddleName: | MARIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KLUSEK | ||||||||
| OtherFirstName: | MALVINA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 104 S VILLAGE AVE APT 1H | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE CENTRE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115705851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175494065 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1300 ROANOKE AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119012031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317271600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2021 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.