Provider Demographics
NPI:1033281639
Name:FUZAYLOV, EMMANUEL (DPM)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:FUZAYLOV
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11056 68TH DR
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2953
Mailing Address - Country:US
Mailing Address - Phone:718-291-9020
Mailing Address - Fax:718-291-9022
Practice Address - Street 1:16110 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:718-291-9020
Practice Address - Fax:718-291-9022
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005841213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U88654Medicare UPIN