Healthcare Provider Details

I. General information

NPI: 1184689523
Provider Name (Legal Business Name): NAIL BAGAUTDINOV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: NAIL BAGAOUTDINOV M.D.

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 11/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W 189TH ST APT 1 C
NEW YORK NY
10040-4039
US

IV. Provider business mailing address

701 W 189TH ST APT 1 C
NEW YORK NY
10040-4039
US

V. Phone/Fax

Practice location:
  • Phone: 646-510-4868
  • Fax:
Mailing address:
  • Phone: 646-510-4868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number39027
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number268055
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: