Provider Demographics
NPI:1154332310
Name:FUZAYLOV, GAVRIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:GAVRIEL
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 1:10210 66TH RD STE 1H
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2047
Mailing Address - Country:US
Mailing Address - Phone:718-897-0327
Mailing Address - Fax:844-965-9107
Practice Address - Street 1:10210 66TH RD STE 1H
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-2047
Practice Address - Country:US
Practice Address - Phone:718-897-0327
Practice Address - Fax:844-965-9107
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200199207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01586676Medicaid
NY01586676Medicaid
NY01895Medicare ID - Type Unspecified