Provider Demographics
NPI:1851930820
Name:KHAFIZOV, DMITRIY
Entity Type:Individual
Prefix:
First Name:DMITRIY
Middle Name:
Last Name:KHAFIZOV
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 1:7319 195TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1839
Mailing Address - Country:US
Mailing Address - Phone:917-945-5344
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKDALE PLZ
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-3139
Practice Address - Country:US
Practice Address - Phone:718-240-5428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024523225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist