Provider Demographics
NPI:1093722183
Name:ILIZAROV, SVETLANA (MD)
Entity Type:Individual
Prefix:DR
First Name:SVETLANA
Middle Name:
Last Name:ILIZAROV
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:HSC 18 ROOM 020 DEPARTMENT OF ORTHOPAEDICS
Mailing Address - Street 2:STONY BROOK UNIVERSITY MEDICAL CENTER
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-0001
Mailing Address - Country:US
Mailing Address - Phone:631-444-6996
Mailing Address - Fax:631-444-7671
Practice Address - Street 1:181 BELLE MEAD RD
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3495
Practice Address - Country:US
Practice Address - Phone:631-444-6996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2008-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215268208100000X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2090022Medicaid
NY2090022Medicaid
NYH23143Medicare UPIN