Healthcare Provider Details

I. General information

NPI: 1184191801
Provider Name (Legal Business Name): RONI RAFAILOV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11835 QUEENS BLVD STE 400
FOREST HILLS NY
11375-7211
US

IV. Provider business mailing address

9810 64TH AVE APT 4F
REGO PARK NY
11374-2502
US

V. Phone/Fax

Practice location:
  • Phone: 646-722-7610
  • Fax: 347-535-3970
Mailing address:
  • Phone: 718-864-5734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number343427
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: