Basic Information
| Provider Information | |||||||||
| NPI: | 1114991106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KULIYEV | ||||||||
| FirstName: | FUAD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9811 W CHARLESTON BLVD | ||||||||
| Address2: | SUITE 2-231 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891177528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023272276 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1800 SPRING RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SUSANVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961306100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302522000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 03/03/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 9498 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2018758 | 05 | NV | MEDICAID |