Provider Demographics
NPI:1578629655
Name:MIRZADZHANOV, IGOR (PT)
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:MIRZADZHANOV
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 E 9TH ST APT 3E
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-5250
Mailing Address - Country:US
Mailing Address - Phone:718-287-8224
Mailing Address - Fax:
Practice Address - Street 1:478 E 9TH ST APT 3E
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-5250
Practice Address - Country:US
Practice Address - Phone:718-287-8224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020363-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist