Provider Demographics
NPI:1093734055
Name:MIKHAYLOV, IZOLDA (DO)
Entity Type:Individual
Prefix:
First Name:IZOLDA
Middle Name:
Last Name:MIKHAYLOV
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 VAN DAM ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3523
Mailing Address - Country:US
Mailing Address - Phone:718-469-0890
Mailing Address - Fax:
Practice Address - Street 1:9815 HORACE HARDING EXPY
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-4249
Practice Address - Country:US
Practice Address - Phone:718-699-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223885207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02313197Medicaid
NY05447Medicare ID - Type UnspecifiedGHI MEDICARE
NY02313197Medicaid
NY54V691Medicare ID - Type Unspecified