Provider Demographics
NPI:1699950899
Name:NIYAZOV, DMITRIY M (MD)
Entity type:Individual
Prefix:
First Name:DMITRIY
Middle Name:M
Last Name:NIYAZOV
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 1:213 CURLEW DR
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-7488
Mailing Address - Country:US
Mailing Address - Phone:504-905-9940
Mailing Address - Fax:504-370-4089
Practice Address - Street 1:905 S LASALLE ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-2429
Practice Address - Country:US
Practice Address - Phone:504-905-9940
Practice Address - Fax:504-370-4089
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.201813207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09334866Medicaid
LA1027987Medicaid
LA4K965Medicare PIN