Provider Demographics
NPI:1316309040
Name:KAGAN, ANATOLIY
Entity type:Individual
Prefix:
First Name:ANATOLIY
Middle Name:
Last Name:KAGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 GLOVER ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-3321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:453 FULTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5207
Practice Address - Country:US
Practice Address - Phone:718-596-6596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC006785-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician