Healthcare Provider Details

I. General information

NPI: 1164665725
Provider Name (Legal Business Name): KONSTANTIN AVERIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2009
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MARCUS AVE STE M15
NEW HYDE PARK NY
11042-1034
US

IV. Provider business mailing address

1111 MARCUS AVE STE M15
NEW HYDE PARK NY
11042-1034
US

V. Phone/Fax

Practice location:
  • Phone: 516-601-7303
  • Fax: 516-601-7380
Mailing address:
  • Phone: 516-601-7303
  • Fax: 516-601-7380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number314684
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: