Provider Demographics
NPI:1295334480
Name:ISMATOV, DJURABEK
Entity type:Individual
Prefix:
First Name:DJURABEK
Middle Name:
Last Name:ISMATOV
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 1:1940 OCEAN AVE APT 6J
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-6729
Mailing Address - Country:US
Mailing Address - Phone:984-377-3777
Mailing Address - Fax:718-744-9774
Practice Address - Street 1:1122 CONEY ISLAND AVE STE A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-2345
Practice Address - Country:US
Practice Address - Phone:833-743-0100
Practice Address - Fax:718-744-9774
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYLA1457148172V00000X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No172V00000XOther Service ProvidersCommunity Health Worker