Provider Demographics
NPI:1609087659
Name:PRAKHINA, BORIS L (MD)
Entity Type:Individual
Prefix:DR
First Name:BORIS
Middle Name:L
Last Name:PRAKHINA
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 1:33-00 BROADWAY
Mailing Address - Street 2:SUITE # 209
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-4617
Mailing Address - Country:US
Mailing Address - Phone:201-796-7666
Mailing Address - Fax:201-796-5570
Practice Address - Street 1:33-00 BROADWAY
Practice Address - Street 2:SUITE # 209
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-4617
Practice Address - Country:US
Practice Address - Phone:201-796-7666
Practice Address - Fax:201-796-5570
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA068923174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7979100Medicaid
NJ088012Medicare ID - Type Unspecified
NJG97801Medicare UPIN