MEDICARE: MARAT G. CHAIKHOUTDINOV MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A87766	CA
2	207Q00000X	Family Medicine Physician	240497	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063590891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARAT G. CHAIKHOUTDINOV MD

Provider Business Mailing Address
First Line	:	105 KINGS HWY
Second Line	:	5C
City	:	BROOKLYN
State	:	NY
Zip	:	11214-1525
Country	:	US
Telephone Number	:	718-513-4386
Fax Number	:

Provider Business Practice Location Address
First Line	:	1513 VOORHIES AVE
Second Line	:	SECOND FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3994
Country	:	US
Telephone Number	:	718-332-4440
Fax Number	:	718-332-5089

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/19/2012

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