Provider Demographics
NPI:1972635753
Name:MULLOKANDOV, SNEZHANA
Entity type:Individual
Prefix:
First Name:SNEZHANA
Middle Name:
Last Name:MULLOKANDOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 NASSAU RD
Mailing Address - Street 2:LONG ISLAND FQHC, INC
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1343
Mailing Address - Country:US
Mailing Address - Phone:516-571-8600
Mailing Address - Fax:
Practice Address - Street 1:380 NASSAU RD
Practice Address - Street 2:LONG ISLAND FQHC, INC.
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-1343
Practice Address - Country:US
Practice Address - Phone:516-571-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY242796207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02864919Medicaid
NY242796OtherNYS LICENSE