Provider Demographics
NPI:1629384342
Name:LUIZA GUSEYNOV,PHYSICIAN,PLLC
Entity Type:Organization
Organization Name:LUIZA GUSEYNOV,PHYSICIAN,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSEYNOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-432-0200
Mailing Address - Street 1:16832 POWELLS COVE BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-1523
Mailing Address - Country:US
Mailing Address - Phone:718-432-0200
Mailing Address - Fax:718-432-0201
Practice Address - Street 1:3108 KINGSBRIDGE AVE
Practice Address - Street 2:GROUND FLOOR,OFFICE B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-3956
Practice Address - Country:US
Practice Address - Phone:718-432-0200
Practice Address - Fax:718-432-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233370261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02625643Medicaid