Provider Demographics
NPI:1063758621
Name:BORUKHOV, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BORUKHOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6838 136TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1626
Mailing Address - Country:US
Mailing Address - Phone:718-619-4982
Mailing Address - Fax:
Practice Address - Street 1:6838 136TH ST APT B
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-1626
Practice Address - Country:US
Practice Address - Phone:718-619-4982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1196084174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist