Provider Demographics
NPI:1487989406
Name:MULOKANDOV, BORIS
Entity type:Individual
Prefix:MR
First Name:BORIS
Middle Name:
Last Name:MULOKANDOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16524 BAISLEY BLVD
Mailing Address - Street 2:STORE #14 MALL #1
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-2517
Mailing Address - Country:US
Mailing Address - Phone:718-276-0055
Mailing Address - Fax:718-276-5059
Practice Address - Street 1:16524 BAISLEY BLVD
Practice Address - Street 2:STORE #14 MALL #1
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-2517
Practice Address - Country:US
Practice Address - Phone:718-276-0055
Practice Address - Fax:718-276-5059
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-08
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008669-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician