Provider Demographics
NPI:1720297872
Name:KHAIMOV, BORIS (DO,)
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:KHAIMOV
Suffix:
Gender:M
Credentials:DO,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6725 DARTMOUTH ST
Mailing Address - Street 2:3N
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4058
Mailing Address - Country:US
Mailing Address - Phone:171-826-3382
Mailing Address - Fax:
Practice Address - Street 1:11 GRACE AVE STE 204
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2417
Practice Address - Country:US
Practice Address - Phone:917-551-6652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2492242084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program