Provider Demographics
NPI:1609851195
Name:KHALDAROV, VITALIY (MD)
Entity Type:Individual
Prefix:
First Name:VITALIY
Middle Name:
Last Name:KHALDAROV
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 1:19615 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366
Mailing Address - Country:US
Mailing Address - Phone:917-816-4597
Mailing Address - Fax:
Practice Address - Street 1:19615 75TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11366-1813
Practice Address - Country:US
Practice Address - Phone:917-816-4597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2180842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY464106OtherVALUE OPTION
NY581076OtherMAGELLAN
NY02119253Medicaid
NYP2574904OtherOXFORD HEALTH PLAN
NYP2574904OtherOXFORD HEALTH PLAN
NY464106OtherVALUE OPTION
NY05047Medicare ID - Type UnspecifiedGHI