Provider Demographics
NPI:1891974507
Name:FUZAYLOV, EDUARD
Entity Type:Individual
Prefix:
First Name:EDUARD
Middle Name:
Last Name:FUZAYLOV
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 1:223 TAYLORS MILLS ROAD
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-3570
Mailing Address - Country:US
Mailing Address - Phone:732-851-6673
Mailing Address - Fax:732-851-6674
Practice Address - Street 1:223 TAYLORS MILLS ROAD
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726
Practice Address - Country:US
Practice Address - Phone:732-851-6673
Practice Address - Fax:732-851-6674
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2458951207R00000X
NY245895207R00000X
NJ25MA08308000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02978834Medicaid
NJ0244899Medicaid
NY02978834Medicaid
NJ0244899Medicaid