Provider Demographics
NPI:1093974040
Name:FUZAYLOV, DMITRIY (MD)
Entity Type:Individual
Prefix:
First Name:DMITRIY
Middle Name:
Last Name:FUZAYLOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9701 66TH AVE
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4245
Mailing Address - Country:US
Mailing Address - Phone:718-275-5200
Mailing Address - Fax:718-275-6864
Practice Address - Street 1:9701 66TH AVE
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4245
Practice Address - Country:US
Practice Address - Phone:718-275-5200
Practice Address - Fax:718-275-6864
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241269208100000X, 207LP2900X
PAMD436995207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400058701Medicare PIN