Healthcare Provider Details

I. General information

NPI: 1528894268
Provider Name (Legal Business Name): RONI RAFAILOV NP FAMILY HEALTH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21805 GRAND CENTRAL PKWY
QUEENS VILLAGE NY
11427-1435
US

IV. Provider business mailing address

21805 GRAND CENTRAL PKWY
QUEENS VILLAGE NY
11427-1435
US

V. Phone/Fax

Practice location:
  • Phone: 718-864-5734
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: RONI RAFAILOV
Title or Position: OWNER
Credential:
Phone: 718-864-5734