Provider Demographics
NPI:1760540447
Name:AGAYEV, RUFAT A
Entity Type:Individual
Prefix:
First Name:RUFAT
Middle Name:A
Last Name:AGAYEV
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 1:7410 RIDGE BLVD
Mailing Address - Street 2:APT 1C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-2355
Mailing Address - Country:US
Mailing Address - Phone:718-238-8724
Mailing Address - Fax:
Practice Address - Street 1:7410 RIDGE BLVD
Practice Address - Street 2:APT 1C
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-2355
Practice Address - Country:US
Practice Address - Phone:718-238-8724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0056751174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02063596Medicaid
NYPB7361Medicare PIN
NYU80248Medicare UPIN
NY06887Medicare PIN