Provider Demographics
NPI:1538333679
Name:MARAT CHAIKHOUTDINOV, MEDICAL P.C.
Entity type:Organization
Organization Name:MARAT CHAIKHOUTDINOV, MEDICAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARAT
Authorized Official - Middle Name:G
Authorized Official - Last Name:CHAIKHOUTDINOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-479-3226
Mailing Address - Street 1:105 KINGS HWY
Mailing Address - Street 2:APT. 5C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-1525
Mailing Address - Country:US
Mailing Address - Phone:209-479-3226
Mailing Address - Fax:718-513-4386
Practice Address - Street 1:1513 VOORHIES AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3994
Practice Address - Country:US
Practice Address - Phone:718-332-4440
Practice Address - Fax:718-332-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240497261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A877660Medicaid
NYI28306OtherUPIN
NY02823449Medicaid
NYI28306OtherUPIN