MEDICARE: MR. ALEX ISANOV

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	:	1962564633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALEX ISANOV

Provider Business Mailing Address
First Line	:	4920 NEW UTRECHT AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-3418
Country	:	US
Telephone Number	:	718-871-5663
Fax Number	:	718-871-5663

Provider Business Practice Location Address
First Line	:	4920 NEW UTRECHT AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-3418
Country	:	US
Telephone Number	:	718-871-5663
Fax Number	:	718-871-5663

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

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	07/08/2007

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