MEDICARE: MARIYA KHAIMOVA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1184265803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIYA KHAIMOVA

Provider Business Mailing Address
First Line	:	6812 YELLOWSTONE BLVD APT 4S
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-3244
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6812 YELLOWSTONE BLVD APT 4S
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-3244
Country	:	US
Telephone Number	:	718-710-9116
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2019
Last Update Date	:	10/03/2019

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Directions to “ MARIYA KHAIMOVA ” Practice Location

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