Healthcare Provider Details

I. General information

NPI: 1912141979
Provider Name (Legal Business Name): PAUL JACK DER MESROPIAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 HOLLAND AVE ALBANY STRATTON VA - DIVISION OF NEPHROLOGY
ALBANY NY
12208-3410
US

IV. Provider business mailing address

113 HOLLAND AVE ALBANY STRATTON VA - DIVISION OF NEPHROLOGY
ALBANY NY
12208-3410
US

V. Phone/Fax

Practice location:
  • Phone: 518-626-5000
  • Fax:
Mailing address:
  • Phone: 518-626-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number270579
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: