Basic Information
| Provider Information | |||||||||
| NPI: | 1922644517 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOVYAZIN | ||||||||
| FirstName: | ARTEM | ||||||||
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| Credential: | PT,DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 ROUTE 9 N | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070951025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018017141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2148 OCEAN AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112291483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188727002 | ||||||||
| FaxNumber: | 7188726899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2019 | ||||||||
| LastUpdateDate: | 11/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 045283 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.