Provider Demographics
NPI:1720650591
Name:SOBIROVA, MUTRIBAKHON
Entity Type:Individual
Prefix:
First Name:MUTRIBAKHON
Middle Name:
Last Name:SOBIROVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2170 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-5571
Mailing Address - Country:US
Mailing Address - Phone:347-554-9074
Mailing Address - Fax:
Practice Address - Street 1:2170 E 9TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-5571
Practice Address - Country:US
Practice Address - Phone:347-554-9074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY817301163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY123456OtherBLUE CROSS BLUE SHIELD