Provider Demographics
NPI:1326110081
Name:SKYLIZARD, LOKI (MD)
Entity Type:Individual
Prefix:
First Name:LOKI
Middle Name:
Last Name:SKYLIZARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8000
Mailing Address - Street 2:DEPT 596
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14267-0002
Mailing Address - Country:US
Mailing Address - Phone:866-295-0041
Mailing Address - Fax:708-342-2517
Practice Address - Street 1:166 MORRIS AVE
Practice Address - Street 2:2ND FL
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6619
Practice Address - Country:US
Practice Address - Phone:732-263-5024
Practice Address - Fax:732-263-5029
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA219576208600000X
ALMD28398208G00000X
PAMD4428472086S0129X
NJ25MA09252000208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102I785476Medicare PIN