Basic Information
| Provider Information | |||||||||
| NPI: | 1942626031 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TYSHKOV | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 263 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112157247 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 263 7TH AVE | ||||||||
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| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187805260 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2014 | ||||||||
| LastUpdateDate: | 08/04/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 288744 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.