Provider Demographics
NPI:1821018359
Name:FATAKHOVA, NAGMO M (MD)
Entity Type:Individual
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First Name:NAGMO
Middle Name:M
Last Name:FATAKHOVA
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Gender:F
Credentials:MD
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Mailing Address - Street 1:4550 KEARNY VILLA RD
Mailing Address - Street 2:SUITE116
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1578
Mailing Address - Country:US
Mailing Address - Phone:858-279-1223
Mailing Address - Fax:619-295-3365
Practice Address - Street 1:9520 63RD RD STE J
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1145
Practice Address - Country:US
Practice Address - Phone:858-279-1223
Practice Address - Fax:619-516-4757
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2018-10-04
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Provider Licenses
StateLicense IDTaxonomies
NY2190092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04321399Medicaid
CA00622960Medicaid
CA00622960Medicaid