Provider Demographics
NPI:1235379827
Name:FUZAILOV, IMANUEL (PT)
Entity Type:Individual
Prefix:
First Name:IMANUEL
Middle Name:
Last Name:FUZAILOV
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-1121
Mailing Address - Country:US
Mailing Address - Phone:718-554-0064
Mailing Address - Fax:718-554-0221
Practice Address - Street 1:721 MELROSE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-1121
Practice Address - Country:US
Practice Address - Phone:718-554-0064
Practice Address - Fax:718-554-0221
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031215225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist