Healthcare Provider Details

I. General information

NPI: 1962409219
Provider Name (Legal Business Name): NIKOLAY BANGIYEV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 04/04/2006

III. Provider practice location address

206 FAIRVIEW PARK DR
DUBLIN GA
31021-2547
US

IV. Provider business mailing address

PO BOX 16550
DUBLIN GA
31040-6550
US

V. Phone/Fax

Practice location:
  • Phone: 478-296-7677
  • Fax:
Mailing address:
  • Phone: 478-296-7677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number049998
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: