Healthcare Provider Details

I. General information

NPI: 1447508064
Provider Name (Legal Business Name): KHAIMOV PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64-05 YELLOWSTONE BLVD CF104
FOREST HILLS NY
11375-5656
US

IV. Provider business mailing address

71-26 YELLOWSTONE BLVD
FOREST HILLS NY
11375-5656
US

V. Phone/Fax

Practice location:
  • Phone: 718-606-2700
  • Fax: 718-606-2715
Mailing address:
  • Phone: 718-606-2700
  • Fax: 718-606-2715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02568129
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: DR. RAFIK KHAIMOV
Title or Position: PRESIDENT
Credential: MD
Phone: 917-776-3092