Provider Demographics
NPI:1184792640
Name:SHKOLNIKOV, TATYANA (MD)
Entity type:Individual
Prefix:DR
First Name:TATYANA
Middle Name:
Last Name:SHKOLNIKOV
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 1:301 MANCHESTER RD STE 105
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-2587
Mailing Address - Country:US
Mailing Address - Phone:845-452-1700
Mailing Address - Fax:845-452-1752
Practice Address - Street 1:301 MANCHESTER RD STE 105
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-2895
Practice Address - Country:US
Practice Address - Phone:845-225-7337
Practice Address - Fax:845-225-1183
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235691207P00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02739577Medicaid