Provider Demographics
NPI:1912082504
Name:FUZAYLOV, OLEG (MD)
Entity Type:Individual
Prefix:DR
First Name:OLEG
Middle Name:
Last Name:FUZAYLOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9701 66TH AVE
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4245
Mailing Address - Country:US
Mailing Address - Phone:718-275-5200
Mailing Address - Fax:718-275-6864
Practice Address - Street 1:9701 66TH AVE
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4245
Practice Address - Country:US
Practice Address - Phone:718-275-5200
Practice Address - Fax:718-275-6864
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220254208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02150154Medicaid
NYH37816Medicare UPIN
NY02150154Medicaid