Provider Demographics
NPI:1760897383
Name:KAKZANOV, ROMAN S (OD)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:S
Last Name:KAKZANOV
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105-24 64RD FOREST HILLS APT 2S
Mailing Address - Street 2:
Mailing Address - City:NY
Mailing Address - State:NY
Mailing Address - Zip Code:11375
Mailing Address - Country:US
Mailing Address - Phone:917-476-7757
Mailing Address - Fax:
Practice Address - Street 1:119-15 ATLANTIC AVENUE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418
Practice Address - Country:US
Practice Address - Phone:718-805-0700
Practice Address - Fax:718-805-5621
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008183-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03966603Medicaid
NYWEE561Medicare PIN
NY00815AMedicare PIN