Healthcare Provider Details

I. General information

NPI: 1417033572
Provider Name (Legal Business Name): AVANGUARD MEDICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2076 E 13TH ST
BROOKLYN NY
11229-3304
US

IV. Provider business mailing address

2076 E 13TH ST
BROOKLYN NY
11229-3304
US

V. Phone/Fax

Practice location:
  • Phone: 718-382-7909
  • Fax: 718-382-7912
Mailing address:
  • Phone: 718-382-7909
  • Fax: 718-382-7912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number205366
License Number StateNY

VIII. Authorized Official

Name: DR. MARK GLADSTEIN
Title or Position: DIRECTOR
Credential: MD
Phone: 718-382-7900