Provider Demographics
NPI:1144090200
Name:IKONOSTASOV, SERGEY
Entity type:Individual
Prefix:
First Name:SERGEY
Middle Name:
Last Name:IKONOSTASOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 TALL OAKS DR
Mailing Address - Street 2:
Mailing Address - City:WARMINSTER
Mailing Address - State:PA
Mailing Address - Zip Code:18974-5209
Mailing Address - Country:US
Mailing Address - Phone:267-261-1121
Mailing Address - Fax:610-595-9203
Practice Address - Street 1:426 TALL OAKS DR
Practice Address - Street 2:
Practice Address - City:WARMINSTER
Practice Address - State:PA
Practice Address - Zip Code:18974-5209
Practice Address - Country:US
Practice Address - Phone:267-261-1121
Practice Address - Fax:610-595-9203
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA153189156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist