Healthcare Provider Details

I. General information

NPI: 1679491047
Provider Name (Legal Business Name): IMRAN BAZOV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: AMI BAZOV

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2959 AVENUE Y
BROOKLYN NY
11235-1624
US

IV. Provider business mailing address

2708 HEALY AVE
FAR ROCKAWAY NY
11691-1808
US

V. Phone/Fax

Practice location:
  • Phone: 718-233-9098
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number005128
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: