MEDICARE: DR. MAISEY KHODZHAYEV

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	183500000X	Pharmacist	065148	NY

General Provider Information

NPI Number	:	1598221152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAISEY KHODZHAYEV

Provider Business Mailing Address
First Line	:	3110 LONG BEACH RD
Second Line	:
City	:	OCEANSIDE
State	:	NY
Zip	:	11572-3200
Country	:	US
Telephone Number	:	516-992-8449
Fax Number	:

Provider Business Practice Location Address
First Line	:	3110 LONG BEACH RD
Second Line	:
City	:	OCEANSIDE
State	:	NY
Zip	:	11572-3200
Country	:	US
Telephone Number	:	516-992-8449
Fax Number	:

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

Provider Enumeration Date	:	02/19/2019
Last Update Date	:	02/19/2019

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