Provider Demographics
NPI:1902103823
Name:TABAK, ROSTISLAV (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSTISLAV
Middle Name:
Last Name:TABAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 MARCUS AVE
Mailing Address - Street 2:APT S27G
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1113
Mailing Address - Country:US
Mailing Address - Phone:516-622-6000
Mailing Address - Fax:
Practice Address - Street 1:401 E 34TH ST
Practice Address - Street 2:APT S27G
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4914
Practice Address - Country:US
Practice Address - Phone:347-575-7180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-13
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG400115204Medicare PIN