Provider Demographics
NPI:1487633772
Name:KAZAKOV, VALERI I (MD)
Entity Type:Individual
Prefix:
First Name:VALERI
Middle Name:I
Last Name:KAZAKOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 AMANDA LANE
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10804
Mailing Address - Country:US
Mailing Address - Phone:718-863-8663
Mailing Address - Fax:718-863-8261
Practice Address - Street 1:2190 BOSTON RD
Practice Address - Street 2:STE 1N
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462
Practice Address - Country:US
Practice Address - Phone:718-863-8663
Practice Address - Fax:718-863-8261
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219298207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02182130Medicaid
H49883Medicare UPIN
NY019AX1Medicare ID - Type Unspecified