Provider Demographics
NPI:1679543888
Name:BADALOV, ILYA (MD)
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:
Last Name:BADALOV
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 1:55 WATER ST FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0004
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:14015 SANFORD AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2686
Practice Address - Country:US
Practice Address - Phone:718-670-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214438207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02288737Medicaid
NY9255QPMedicare PIN
NY02288737Medicaid