Provider Demographics
NPI:1710399589
Name:KAZAKIN, ANATOLY
Entity Type:Individual
Prefix:
First Name:ANATOLY
Middle Name:
Last Name:KAZAKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PAGE ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-3464
Mailing Address - Country:US
Mailing Address - Phone:508-973-5771
Mailing Address - Fax:
Practice Address - Street 1:101 PAGE ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-3464
Practice Address - Country:US
Practice Address - Phone:508-973-5771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA283419207P00000X
RIMD16801207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110156708AMedicaid