Provider Demographics
NPI:1962409219
Name:BANGIYEV, NIKOLAY (MD)
Entity type:Individual
Prefix:DR
First Name:NIKOLAY
Middle Name:
Last Name:BANGIYEV
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 16550
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31040-6550
Mailing Address - Country:US
Mailing Address - Phone:478-296-7677
Mailing Address - Fax:
Practice Address - Street 1:206 FAIRVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2547
Practice Address - Country:US
Practice Address - Phone:478-296-7677
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-01
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
GA049998174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA140466XXOtherPHCS,PREFERRED CARE
GA52864485OtherBLUE CROSS BLUE SHIELD
GA00916253AMedicaid
GA52864485OtherBLUE CROSS BLUE SHIELD
GA140466XXOtherPHCS,PREFERRED CARE