Provider Demographics
NPI:1528485752
Name:NISON L BADALOV MD PC
Entity type:Organization
Organization Name:NISON L BADALOV MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NISON
Authorized Official - Middle Name:L
Authorized Official - Last Name:BADALOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-520-0857
Mailing Address - Street 1:107-21 QUEENS BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4451
Mailing Address - Country:US
Mailing Address - Phone:718-520-0857
Mailing Address - Fax:718-520-9099
Practice Address - Street 1:107-21 QUEENS BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4451
Practice Address - Country:US
Practice Address - Phone:718-520-0857
Practice Address - Fax:718-520-9099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY242278207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty