MEDICARE: NAGMO M FATAKHOVA M.D.

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	2084P0800X	Psychiatry Physician	219009	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821018359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NAGMO M FATAKHOVA M.D.

Provider Business Mailing Address
First Line	:	4550 KEARNY VILLA RD
Second Line	:	SUITE116
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1578
Country	:	US
Telephone Number	:	858-279-1223
Fax Number	:	619-295-3365

Provider Business Practice Location Address
First Line	:	9520 63RD RD STE J
Second Line	:
City	:	REGO PARK
State	:	NY
Zip	:	11374-1145
Country	:	US
Telephone Number	:	858-279-1223
Fax Number	:	619-516-4757

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	10/04/2018

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