Provider Demographics
NPI:1487265922
Name:HAIDATOV, OFER (FNP)
Entity type:Individual
Prefix:MR
First Name:OFER
Middle Name:
Last Name:HAIDATOV
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7536 BELL BLVD APT 6B
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-3434
Mailing Address - Country:US
Mailing Address - Phone:646-898-7422
Mailing Address - Fax:
Practice Address - Street 1:7536 BELL BLVD APT 6B
Practice Address - Street 2:
Practice Address - City:OAKLAND GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11364-3434
Practice Address - Country:US
Practice Address - Phone:646-898-7422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346340363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily