MEDICARE: BORIS N FATAKHOV 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	2084P0800X	Psychiatry Physician	231567	NY

General Provider Information

NPI Number	:	1871571448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BORIS N FATAKHOV MD

Provider Business Mailing Address
First Line	:	7111 YELLOWSTONE BLVD
Second Line	:	APT 2P
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-3541
Country	:	US
Telephone Number	:	718-575-1547
Fax Number	:

Provider Business Practice Location Address
First Line	:	606 WINTHROP ST
Second Line	:	6 BUILDING
City	:	BROOKLYN
State	:	NY
Zip	:	11203-1709
Country	:	US
Telephone Number	:	718-245-2362
Fax Number	:

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

Provider Enumeration Date	:	01/04/2006
Last Update Date	:	07/08/2007

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