MEDICARE: DR. DIANA NURUTDINOVA 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	207R00000X	Internal Medicine Physician	2006020982	MO
2	207RI0200X	Infectious Disease Physician	284731-1	NY

General Provider Information

NPI Number	:	1386704302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANA NURUTDINOVA MD

Provider Business Mailing Address
First Line	:	450 W 147TH ST
Second Line	:	APT 42
City	:	NEW YORK
State	:	NY
Zip	:	10031-3803
Country	:	US
Telephone Number	:	212-523-4000
Fax Number	:	212-523-5677

Provider Business Practice Location Address
First Line	:	440 W 114TH ST
Second Line	:	6TH FLOOR
City	:	NEW YORK
State	:	NY
Zip	:	10025-1796
Country	:	US
Telephone Number	:	212-523-4000
Fax Number	:	212-523-5677

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	06/29/2016

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