=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902859440
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GALINA KRUGLYAKOVA OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2006
-----------------------------------------------------
Last Update Date | 01/31/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3511 QUENTIN RD
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11234-4230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-377-1021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2421 OCEAN AVE APT 5B
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11229-3566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-934-4625
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV006784
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------