Healthcare Provider Details

I. General information

NPI: 1972831733
Provider Name (Legal Business Name): EDWARD BANGIYEV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2009
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 W 125TH ST
NEW YORK NY
10027-3641
US

IV. Provider business mailing address

328 W 125TH ST
NEW YORK NY
10027-3641
US

V. Phone/Fax

Practice location:
  • Phone: 212-663-2020
  • Fax:
Mailing address:
  • Phone: 212-663-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number008630
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: