1538333679 NPI number — MARAT CHAIKHOUTDINOV, MEDICAL P.C.

Table of content: (NPI 1538333679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538333679 NPI number — MARAT CHAIKHOUTDINOV, MEDICAL P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARAT CHAIKHOUTDINOV, MEDICAL 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:
1538333679
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 KINGS HWY
Provider Second Line Business Mailing Address:
APT. 5C
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11214-1525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-479-3226
Provider Business Mailing Address Fax Number:
718-513-4386

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1513 VOORHIES AVE
Provider Second Line Business Practice Location Address:
SECOND FLOOR
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11235-3994
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-332-4440
Provider Business Practice Location Address Fax Number:
718-332-0077
Provider Enumeration Date:
04/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CHAIKHOUTDINOV
Authorized Official First Name:
MARAT
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
209-479-3226

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  240497 , 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)

  • Identifier: 00A877660 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: I28306 . This is a "UPIN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02823449 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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