Provider Demographics
NPI:1417310517
Name:MIZHQUIRI, SANDRO
Entity Type:Individual
Prefix:
First Name:SANDRO
Middle Name:
Last Name:MIZHQUIRI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 44TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-1634
Mailing Address - Country:US
Mailing Address - Phone:718-633-4400
Mailing Address - Fax:718-437-7705
Practice Address - Street 1:802 44TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-1634
Practice Address - Country:US
Practice Address - Phone:718-633-4400
Practice Address - Fax:718-437-7705
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYB02905344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi