=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336481134
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIGRAN GEVORGYAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2013
-----------------------------------------------------
Last Update Date | 03/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 DEKALB AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11201-5425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-250-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 ROOSEVELT AVE
-----------------------------------------------------
City | ELMWOOD PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07407-1031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-316-1932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | P86757
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------