Healthcare Provider Details

I. General information

NPI: 1598694820
Provider Name (Legal Business Name): MIKHAIL ILIATOV NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6802 RIDGE BLVD APT 3B
BROOKLYN NY
11220-5817
US

IV. Provider business mailing address

6802 RIDGE BLVD APT 3B
BROOKLYN NY
11220-5817
US

V. Phone/Fax

Practice location:
  • Phone: 347-724-3435
  • Fax:
Mailing address:
  • Phone: 347-724-3435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF312747-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: