Provider Demographics
NPI:1437796570
Name:MAZITOVA, MADINA
Entity Type:Individual
Prefix:
First Name:MADINA
Middle Name:
Last Name:MAZITOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 RICHMOND AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-1520
Mailing Address - Country:US
Mailing Address - Phone:718-556-1616
Mailing Address - Fax:718-442-9962
Practice Address - Street 1:1535 RICHMOND AVE FL 3
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-1520
Practice Address - Country:US
Practice Address - Phone:718-556-1616
Practice Address - Fax:718-442-9962
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty