Provider Demographics
NPI:1306147657
Name:RAKHIMOVA, LILIYA
Entity type:Individual
Prefix:
First Name:LILIYA
Middle Name:
Last Name:RAKHIMOVA
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 1:8028 COOPER AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-7711
Mailing Address - Country:US
Mailing Address - Phone:718-416-3937
Mailing Address - Fax:
Practice Address - Street 1:520 8TH AVE
Practice Address - Street 2:9TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-6507
Practice Address - Country:US
Practice Address - Phone:212-729-5344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-03
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0090911156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
11/03/2010OtherTODAYS APPLICATION DATE