Healthcare Provider Details

I. General information

NPI: 1982969788
Provider Name (Legal Business Name): GAVRIIL ILIZAROV D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2012
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 E 38TH ST FL 15
NEW YORK NY
10016-2708
US

IV. Provider business mailing address

550 1ST AVE
NEW YORK NY
10016-6402
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-6037
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number280530
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: