Basic Information
| Provider Information | |||||||||
| NPI: | 1083600647 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VYSKOCILOVA | ||||||||
| FirstName: | MARKETA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 CLARKSON AVE | ||||||||
| Address2: | BOX 1262 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112032056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182708867 | ||||||||
| FaxNumber: | 7182701794 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 CLARKSON AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112032056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182702430 | ||||||||
| FaxNumber: | 7182703840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 214029-1 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 02174647 | 05 | NY | MEDICAID |