Provider Demographics
NPI:1871783472
Name:MAMISTVALOV, RAGI (OD)
Entity type:Individual
Prefix:DR
First Name:RAGI
Middle Name:
Last Name:MAMISTVALOV
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 SADDLE ROCK ROAD
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741
Mailing Address - Country:US
Mailing Address - Phone:631-319-1293
Mailing Address - Fax:
Practice Address - Street 1:2707 SADDLE ROCK ROAD
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741
Practice Address - Country:US
Practice Address - Phone:631-319-1293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0064581152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist