Provider Demographics
NPI:1306876248
Name:SAMEDOV, NIKOLAY (MD)
Entity type:Individual
Prefix:DR
First Name:NIKOLAY
Middle Name:
Last Name:SAMEDOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2000
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2000
Mailing Address - Country:US
Mailing Address - Phone:518-828-8363
Mailing Address - Fax:518-697-3388
Practice Address - Street 1:345 ROUTE 296
Practice Address - Street 2:
Practice Address - City:HENSONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12439
Practice Address - Country:US
Practice Address - Phone:518-734-3260
Practice Address - Fax:518-734-5289
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002423207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02717224Medicaid
NY3145P1Medicare PIN
I45178Medicare UPIN