Provider Demographics
NPI:1841578077
Name:MUSHYAKOV, ROMAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:
Last Name:MUSHYAKOV
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 STONY BROOK RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2206
Mailing Address - Country:US
Mailing Address - Phone:631-751-5743
Mailing Address - Fax:
Practice Address - Street 1:1320 STONY BROOK RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2206
Practice Address - Country:US
Practice Address - Phone:631-751-5743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055170183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist