Provider Demographics
NPI:1952395303
Name:FATTAKHOV, VYACHESLAV (MD)
Entity Type:Individual
Prefix:DR
First Name:VYACHESLAV
Middle Name:
Last Name:FATTAKHOV
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 1:108 BURNHAM AVE
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-1935
Mailing Address - Country:US
Mailing Address - Phone:718-795-7586
Mailing Address - Fax:347-826-4155
Practice Address - Street 1:108 BURNHAM AVE
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-1935
Practice Address - Country:US
Practice Address - Phone:718-795-7586
Practice Address - Fax:347-826-4155
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231594-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02591748Medicaid
NYWHNA21OtherMEDICARE
NY02591748Medicaid
NYI16553Medicare UPIN