Provider Demographics
NPI:1841535218
Name:TAKHALOV, BORIS (OPTICIAN)
Entity type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:TAKHALOV
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 N FRANKLIN ST
Mailing Address - Street 2:INSIDE NWL
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-2155
Mailing Address - Country:US
Mailing Address - Phone:516-493-9323
Mailing Address - Fax:
Practice Address - Street 1:111 HEMPSTEAD TPKE
Practice Address - Street 2:INSIDE NWL
Practice Address - City:WEST HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11552-2155
Practice Address - Country:US
Practice Address - Phone:516-493-9323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009414-1156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist