Provider Demographics
NPI:1043455645
Name:FASTOVSKY, IVGENIJA (MD)
Entity type:Individual
Prefix:DR
First Name:IVGENIJA
Middle Name:
Last Name:FASTOVSKY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19111 COLLINS AVE APT 2505
Mailing Address - Street 2:
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-2384
Mailing Address - Country:US
Mailing Address - Phone:305-933-6873
Mailing Address - Fax:305-933-6873
Practice Address - Street 1:19111 COLLINS AVE APT 2505
Practice Address - Street 2:
Practice Address - City:SUNNY ISLES BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-2384
Practice Address - Country:US
Practice Address - Phone:305-933-6873
Practice Address - Fax:305-933-6873
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 591092084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP 55311OtherMEDICARE GHI
NY00580525Medicaid
NYP 55311OtherMEDICARE GHI