Provider Demographics
NPI:1790072320
Name:SAIDOV, REVITTAL (MS)
Entity Type:Individual
Prefix:
First Name:REVITTAL
Middle Name:
Last Name:SAIDOV
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:759 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-2259
Mailing Address - Country:US
Mailing Address - Phone:718-692-1008
Mailing Address - Fax:
Practice Address - Street 1:759 E 8TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-2259
Practice Address - Country:US
Practice Address - Phone:718-692-1008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-04
Last Update Date:2011-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3475285863OtherDYNAMIC THERAPEUTIC SERVICES