=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700278413
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KHATUNA BELOV, MD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2015
-----------------------------------------------------
Last Update Date | 03/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 127 UNION ST STE 102
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07450-4436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-857-0066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 127 UNION ST STE 102
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07450-4436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-857-0066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DOCTOR
-----------------------------------------------------
Name | DR. KHATUNA BELOV
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 201-857-0066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 25MA07761000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------