Healthcare Provider Details

I. General information

NPI: 1043577943
Provider Name (Legal Business Name): MIKHAIL I. KHAIMOV D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 BAY AVE STE 300B
GLEN RIDGE NJ
07028-1607
US

IV. Provider business mailing address

311 BAY AVE STE 300B
GLEN RIDGE NJ
07028-1607
US

V. Phone/Fax

Practice location:
  • Phone: 973-798-4777
  • Fax: 201-523-9550
Mailing address:
  • Phone: 973-798-4777
  • Fax: 201-523-9550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number272593
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: