Healthcare Provider Details

I. General information

NPI: 1457041022
Provider Name (Legal Business Name): ORLY FYZAKOV
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 OAK GLEN RD
HOWELL NJ
07731-8616
US

IV. Provider business mailing address

44 CUSHMAN ST
LAKEWOOD NJ
08701-5201
US

V. Phone/Fax

Practice location:
  • Phone: 732-503-6119
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: