Healthcare Provider Details

I. General information

NPI: 1326057548
Provider Name (Legal Business Name): IGOR Z AVAGYAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 04/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

397 SKI TRL
KINNELON NJ
07405-2247
US

IV. Provider business mailing address

397 SKI TRL
KINNELON NJ
07405-2247
US

V. Phone/Fax

Practice location:
  • Phone: 917-494-8226
  • Fax: 212-426-1409
Mailing address:
  • Phone: 917-494-8226
  • Fax: 212-426-1409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number218312
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA07456200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: