Healthcare Provider Details

I. General information

NPI: 1730527599
Provider Name (Legal Business Name): LYUDMILA MASHKABOV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 10/03/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6625 103RD ST APT. 3X
FOREST HILLS NY
11375-2001
US

IV. Provider business mailing address

6625 103RD ST APT. 3X
FOREST HILLS NY
11375-2001
US

V. Phone/Fax

Practice location:
  • Phone: 646-404-1258
  • Fax: 718-459-4045
Mailing address:
  • Phone: 646-404-1258
  • Fax: 718-459-4045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number391260101
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: