Provider Demographics
NPI:1649626953
Name:FUZAYLOV, STAN (OPTHALMIC DESPENCER)
Entity type:Individual
Prefix:
First Name:STAN
Middle Name:
Last Name:FUZAYLOV
Suffix:
Gender:M
Credentials:OPTHALMIC DESPENCER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-5584
Mailing Address - Country:US
Mailing Address - Phone:212-535-4469
Mailing Address - Fax:
Practice Address - Street 1:1295 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5584
Practice Address - Country:US
Practice Address - Phone:212-535-4469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009893156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician