Provider Demographics
NPI:1003911033
Name:FUZAYLOVA, SVETLANA (MD)
Entity Type:Individual
Prefix:
First Name:SVETLANA
Middle Name:
Last Name:FUZAYLOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SVETLANA
Other - Middle Name:
Other - Last Name:MAVASHEV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4402 FRANCIS LEWIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3041
Mailing Address - Country:US
Mailing Address - Phone:718-631-0500
Mailing Address - Fax:718-281-1276
Practice Address - Street 1:4402 FRANCIS LEWIS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3041
Practice Address - Country:US
Practice Address - Phone:718-631-0500
Practice Address - Fax:718-281-1276
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214465207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01987957Medicaid
H02728Medicare UPIN
NY01987957Medicaid
NY07641KMedicare PIN