Healthcare Provider Details

I. General information

NPI: 1801087572
Provider Name (Legal Business Name): IGOR M POVZHITKOV M D P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 ELLEN PL
PARAMUS NJ
07652-5506
US

IV. Provider business mailing address

343 ELLEN PL
PARAMUS NJ
07652-5506
US

V. Phone/Fax

Practice location:
  • Phone: 201-218-6439
  • Fax:
Mailing address:
  • Phone: 201-218-6439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number23278
License Number StateNJ

VIII. Authorized Official

Name: DR. IGOR M POVZHITKOV
Title or Position: PRESIDENT
Credential: M.D.
Phone: 201-218-6439