1215268669 NPI number — REGO PARK MEDICAL ASSOCIATE,P.C

Table of content: (NPI 1215268669)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215268669 NPI number — REGO PARK MEDICAL ASSOCIATE,P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REGO PARK MEDICAL ASSOCIATE,P.C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215268669
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10210 66TH RD STE 1H
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST HILLS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11375-2047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-897-0327
Provider Business Mailing Address Fax Number:
844-965-9107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9851 QUEENS BLVD
Provider Second Line Business Practice Location Address:
SUITE 1D
Provider Business Practice Location Address City Name:
REGO PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11374-4362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-897-0327
Provider Business Practice Location Address Fax Number:
718-897-0237
Provider Enumeration Date:
01/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
FUZAYLOV
Authorized Official First Name:
GAVRIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
718-897-0327

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  200199 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com