Provider Demographics
NPI:1962764092
Name:MIKAILOV, ANAR (MD)
Entity type:Individual
Prefix:
First Name:ANAR
Middle Name:
Last Name:MIKAILOV
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 1:2150 S CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2618
Mailing Address - Country:US
Mailing Address - Phone:585-256-0555
Mailing Address - Fax:585-256-0583
Practice Address - Street 1:2150 S CLINTON AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2618
Practice Address - Country:US
Practice Address - Phone:585-256-0555
Practice Address - Fax:585-256-0583
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA252998207N00000X, 390200000X
MA226434207N00000X
NY313757207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06875396Medicaid