Provider Demographics
NPI:1447508064
Name:KHAIMOV PEDIATRICS PLLC
Entity type:Organization
Organization Name:KHAIMOV PEDIATRICS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFIK
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAIMOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-776-3092
Mailing Address - Street 1:71-26 YELLOWSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5656
Mailing Address - Country:US
Mailing Address - Phone:718-606-2700
Mailing Address - Fax:718-606-2715
Practice Address - Street 1:64-05 YELLOWSTONE BLVD
Practice Address - Street 2:CF104
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-5656
Practice Address - Country:US
Practice Address - Phone:718-606-2700
Practice Address - Fax:718-606-2715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02568129Medicaid