Provider Demographics
NPI:1508188087
Name:AGAZAROVA, MAZAL (PT)
Entity Type:Individual
Prefix:
First Name:MAZAL
Middle Name:
Last Name:AGAZAROVA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 AVENUE X
Mailing Address - Street 2:APT 5F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-1249
Mailing Address - Country:US
Mailing Address - Phone:718-908-6630
Mailing Address - Fax:718-975-8637
Practice Address - Street 1:3003 AVENUE X
Practice Address - Street 2:APT 5F
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-1249
Practice Address - Country:US
Practice Address - Phone:718-908-6630
Practice Address - Fax:718-975-8637
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYLICENSE#Other032297-1