Healthcare Provider Details

I. General information

NPI: 1760897383
Provider Name (Legal Business Name): ROMAN S KAKZANOV OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119-15 ATLANTIC AVENUE
RICHMOND HILL NY
11418
US

IV. Provider business mailing address

105-24 64RD FOREST HILLS APT 2S
NY NY
11375
US

V. Phone/Fax

Practice location:
  • Phone: 718-805-0700
  • Fax: 718-805-5621
Mailing address:
  • Phone: 917-476-7757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV008183-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: