Provider Demographics
NPI:1508388422
Name:FUZAYLOV, BELLA (SI)
Entity Type:Individual
Prefix:
First Name:BELLA
Middle Name:
Last Name:FUZAYLOV
Suffix:
Gender:F
Credentials:SI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 CORTELYOU RD APT 5K
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-5291
Mailing Address - Country:US
Mailing Address - Phone:917-297-0081
Mailing Address - Fax:
Practice Address - Street 1:130 BRIGHTON 11TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5327
Practice Address - Country:US
Practice Address - Phone:171-874-3184
Practice Address - Fax:718-743-1841
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1256153174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist