Provider Demographics
NPI:1538745278
Name:NIYAZOV, RICHARD (DO)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:NIYAZOV
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 NICOLLS ROAD HSC
Mailing Address - Street 2:HSC LEVEL 4, 050
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794
Mailing Address - Country:US
Mailing Address - Phone:631-444-3880
Mailing Address - Fax:631-444-3919
Practice Address - Street 1:101 NICOLLS ROAD HSC
Practice Address - Street 2:HSC LEVEL 4, 050
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794
Practice Address - Country:US
Practice Address - Phone:631-444-3880
Practice Address - Fax:631-444-3919
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY33008301207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program