Provider Demographics
NPI:1174129803
Name:CENTRAL PARK
Entity type:Organization
Organization Name:CENTRAL PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHAHNOZ
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSTAMOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-391-3414
Mailing Address - Street 1:280 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-1234
Mailing Address - Country:US
Mailing Address - Phone:646-391-3414
Mailing Address - Fax:212-974-0493
Practice Address - Street 1:280 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-1234
Practice Address - Country:US
Practice Address - Phone:646-391-3414
Practice Address - Fax:212-974-0493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY245082Medicaid