Healthcare Provider Details

I. General information

NPI: 1780511865
Provider Name (Legal Business Name): ELLIOT MIKHAYLOV
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 NORTHERN BLVD
GREENVALE NY
11548-1319
US

IV. Provider business mailing address

720 NORTHERN BLVD
GREENVALE NY
11548-1319
US

V. Phone/Fax

Practice location:
  • Phone: 516-299-2900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF360163-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: