Basic Information
| Provider Information | |||||||||
| NPI: | 1659346815 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VENIKOVA | ||||||||
| FirstName: | GALINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2220 AVE U | ||||||||
| Address2: | APT.#1 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112293648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189347081 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1009 BRIGHTON BEACH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112355659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189758500 | ||||||||
| FaxNumber: | 7189758502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 12/08/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 238461 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02723182 | 05 | NY | MEDICAID |