Basic Information
Provider Information | |||||||||
NPI: | 1891731667 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PODOLTSEV | ||||||||
FirstName: | NIKOLAI | ||||||||
MiddleName: | ALEXANDROVICH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D., PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 208032 | ||||||||
Address2: | YALE UNIVERSITY SCHOOL OF MEDICINE, HEMATOLOGY DIVISION | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065208032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2032004363 | ||||||||
FaxNumber: | 2037853788 | ||||||||
Practice Location | |||||||||
Address1: | 333 CEDAR ST | ||||||||
Address2: | YALE UNIVERSITY SCHOOL OF MEDICINE, HEMATOLOGY DIVISION | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065103206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2032004363 | ||||||||
FaxNumber: | 2037853788 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2006 | ||||||||
LastUpdateDate: | 01/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 038990 | CT | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RX0202X | 038990 | CT | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | 038990 | CT | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0000X | 038990 | CT | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology |
ID Information
ID | Type | State | Issuer | Description | 001389908 | 05 | CT |   | MEDICAID |