Provider Demographics
NPI:1447259841
Name:KATSMAN, TATYANA (DO)
Entity type:Individual
Prefix:DR
First Name:TATYANA
Middle Name:
Last Name:KATSMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2690 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-5804
Mailing Address - Country:US
Mailing Address - Phone:201-451-1601
Mailing Address - Fax:
Practice Address - Street 1:3974 AMBOY RD STE 302
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-2414
Practice Address - Country:US
Practice Address - Phone:718-967-1071
Practice Address - Fax:888-908-8284
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB073901207Q00000X
NY291980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05353219OtherMEDICAID
NJ0079367Medicaid
NY05353219Medicaid
NY291980OtherSTATE LICENSE