Provider Demographics
NPI:1851837272
Name:KHAMITOV, RUSLAN
Entity Type:Individual
Prefix:
First Name:RUSLAN
Middle Name:
Last Name:KHAMITOV
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 1:4619 CRESTVIEW LANE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2415
Mailing Address - Country:US
Mailing Address - Phone:863-944-6935
Mailing Address - Fax:
Practice Address - Street 1:4619 CRESTVIEW LN
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2415
Practice Address - Country:US
Practice Address - Phone:863-944-6935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15-284246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant