Basic Information
| Provider Information | |||||||||
| NPI: | 1780230706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOUKHOV | ||||||||
| FirstName: | ELENA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 247 NEWARK AVE # 412 | ||||||||
| Address2: | |||||||||
| City: | JERSEY CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 073022630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018307781 | ||||||||
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| Practice Location | |||||||||
| Address1: | 355 GRAND ST | ||||||||
| Address2: | |||||||||
| City: | JERSEY CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 073024321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019152000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2019 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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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.