Provider Demographics
NPI:1679016430
Name:DZHURAYEVA, MARINA
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:DZHURAYEVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9966 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3653
Mailing Address - Country:US
Mailing Address - Phone:347-527-8408
Mailing Address - Fax:
Practice Address - Street 1:9966 65TH AVE
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3653
Practice Address - Country:US
Practice Address - Phone:347-527-8408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY642523121174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY642523121Medicaid